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 Contact Us > Primary Care Physician Request/Change Primary Care Physician Request

If you or a family member would like to change your current Primary Care Physician, or if you have not selected a Primary Care Physician yet and wish do so, please fill out this form.

* - denotes a required field

Primary Care Physician Request/Change Primary Care Physician Request

Member Name *

Member ID *

Group Number

Previous Primary Care Physician

Name

Provider ID

Address

New Primary Care Physician

Name *

Provider ID *

Address

Address 2

City

State

Zipcode

Please be sure to verify with AHP Member Services 1(866) 747-8422 or the Provider Directory that the new chosen Primary Care Physician is an Atlantis Health Plan contracted physician.