Caresource PCP change form

Provider/Facility:

OR Stamp:

Tax ID#:

Phone:

Member Information:

Member name:

Member phone#:

Member ID# or DOB:

Other Family Members:

Add Family Members

Reason for Change:

No Reason — I just want a different doctor on my card

More convenient location/hours

Referral by family/friend

I am an existing patient with this doctor. I did not request this doctor when I enrolled with Humana – CareSource™.

Dissatisfaction — A Humana – CareSource representative will contact you upon receipt of request.

I requested this PCP when I enrolled, but Humana – CareSource assigned a different doctor on my Humana – CareSource ID card.

I want to be contacted by a Humana – CareSource representative to discuss the change.

The required fields must be completed for the change to be processed. Members can continue to be treated by the requested PCP until the change is complete. The member should continue to use their current ID card until the new ID card is received. All requests will be processed within 3-5 business days of receipt.

Member/Member Representative Signature

Date

Provider (staff) Signature

Date

Fax requests to Humana – CareSource Member Services at (937) 226-6916

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