Source

Requester information

First name

Last name

Phone

Requester's plan medical group (PMG)

Member information

First name

Middle name

Last name

Member's ID

You can find this on their ID card.

Date of birth

Current primary care physician

Address

City

State

ZIP code

Phone

Mobile

Name of new provider

Provider NPI

Plan medical group (PMG)

Have you confirmed that the doctor you are requesting is accepting new patients?

Yes

Reason for requesting for reassignment

Please explain