Primary Care Provider Change

Online Form

Contra Costa Health Plan
595 Center Avenue, Suite 100
Martinez, CA 94553
877-661-6230

To change your Primary Care Provider, please use the Online Form below then Submit.

Note: all fields must be completed.

LAST Name:
FIRST Name:
Middle Initial:
Birthdate: (mm/dd/yyyy)	/ /
Telephone Number: (999-999-9999)	Home: Cellphone:
E-mail:
Home Street Address:
City:
State:
Zip:
Member I.D. # (found on CCHP ID Card) OR Last 4 digits of your Social Security Number:
Please choose from the List of Providers who are accepting new patients this month. Once you have made your selection, complete the section below. If you need to change Primary Care Providers for other members of the family, complete separate requests for each person. For Medi-Cal members requesting a change to Kaiser Services you must have been a member of Kaiser within the past 12 months or meet one of the other criteria. You must include the Kaiser Member Identification Number requested below. Note: when your request is processed you will receive email confirmation.
Desired Primary Care Provider:	Provider FIRST Name: Provider LAST Name:
Provider Address:
Clinic:
Why are you asking for a different assigned PCP? (Check all that apply)	I want the same PCP for all my children. I want the PCP I have seen before. I want a PCP closer to home or other location. I want a PCP to meet certain needs or preferences I have (e.g., language, ethnicity, gender). I am not happy about the service or treatment I received from my currently assigned PCP. I am having trouble getting an appointment from my currently assigned PCP. I want to choose my own PCP for other reasons.
If requesting Kaiser, answer the questions below: Is the member listed above a Kaiser member in the last 12 months? Yes ≫ Enter the member's Kaiser number: ≫ Skip question (b) and go to next question No ≫ Answer question (b) Tell us about the qualified family member (an immediate family member living in the same household and is a current Kaiser member)? Name (first and last) of qualified family member: Relationship of qualified family member to member listed above (e.g., spouse, child, parent / guardian, etc): Qualified family member's Kaiser Number:
Name of person submitting request:	Relationship to member:
Contra Costa Health Services (CCHS) uses automated calls to tell people about important health-related services & benefits or changes to your healthcare coverage. Your information is kept private and secure. Members or parents / guardians of minors completing this online form agree to allow Contra Costa Health Services (CCHS) to communicate with you in this way. (Note: This is especially important for Kaiser assignment requests. It's the easiest way to get a status update.) Members who do not want to provide consent may call Member Services to change their PCP. If you are changing your PCP, we will change it the next business day. We will call you if there are any issues. You can check your PCP by calling 1-877-661-6230, Option 9. If you are asking for Kaiser, you will get an automated call within 3 business days telling you if and when you will be assigned to Kaiser.

If this form was not completed by member or member's legal guardian, we will be unable to process request without member's explicit agreement.