Use this form to let us know that you are changing your Primary Care Provider (PCP). You must
complete each section of the form. Incomplete forms cannot be processed. Members can also
change a PCP over the phone by calling 1-888-FIDELIS (1-888-343-3547).
Member - Primary Care Provider (PCP) Change Request Form
PLEASE PRINT
1. Member Information
First
Name
Last
Name
Date
of Birth
MM
DD
YYYY
Fidelis Care Member ID# (first 9 digits)
Is member a newborn? • Yes • No
2. New Primary Care Provider (PCP) Information
First
Name
Last
Name
Telephone
Number
Practice
Name
Fax
Number
Practice
Address
Provider TIN*: (9 digits)
*TIN must match the Office Address the member will utilize
PCP Change Effective Date: Typically the 1st of the month when the form is received by Fidelis Care.
3. Provider Attestation (PCP)
I (Fidelis Care provider) hereby attest that the above member has granted consent to change
their PCP to the aforementioned provider documented in #2 above.
Today’s
Date
Provider Signature
MM
DD
YYYY
4. Send us the completed form
Fax the completed form to 833-710-2220.
The following Fidelis Care plans do not require PCP assignments: Fidelis Care at Home (MLTC),
Qualified Health Plans, Wellcare By Fidelis Care Dual, and Wellcare By Fidelis Care Medicare.
Providers should always verify a member's PCP assignment via Fidelis Care's Provider
Access Online at providers.fideliscare.org, or by contacting the Provider Call Center at
1-888-FIDELIS (1-888-343-3547).
PCP Change Request Form 01.2024
