Primary Care Physician Change Request Form

(To be completed by the Member)

(Please Print Clearly)

Member Name: ____________________ Date of Birth: ___________________

Member Number: _________________________ Phone Number: _________________

Member Signature: __________________________ Date: ________________________

Current Primary Care Physician

Name: _______________________Group/Location: ___________________________

New Primary Care Physician

Name: _______________________Group/Location: ___________________________

Effective Date of New Primary Care Physician: ________________________________

Reason for Change: _______________________________________________________

Staff Name: __________________________ Date: _____________________________

(Please Print)

Staff Signature: _________________________ Phone Number: ___________________

Please submit copy to Health Plan of Nevada at:

Health Plan of Nevada, Inc.

Attn: Member Services Correspondence Or Fax: (702) 240-6281

2720 N. Tenaya Way

Las Vegas, NV 89128

All change requests are subject to verification and provider availability.