Member - Primary Care Provider (PCP) Change Request Form Update
2020/2/18
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Posted by Provider Relations
The Member - Primary Care Provider (PCP) Change Request Form has been updated and is available on this site. Providers are asked to attest for a patient’s PCP change by signing, dating and faxing a completed form to fax number: 718-393-6635.
Please download: Primary Care Provider Change Request Form.
Primary Care Provider Change Request Form (Spanish)