Feedback
En Español
TRS Home ยป TRS - PCP Change Request

Change Your PCP Online

Scott & White Health Plan
Change of Personal Care Physician (PCP)

 

* Items required to process this form.

Subscriber Information
* Subscriber's Contract Number:
(first 9 digits of your id number on your medical card)
* Subscriber's First Name:
* Subscriber's Last Name:
E-mail:
Member
* First Name:
* Last Name:
* DOB:
* Relationship to Subscriber:
Other:
* New Physician Name:
Reason for Change:
Other, please explain:
Member
First Name:
Last Name:
DOB
Relationship to Subscriber:
Other:
New Physician Name:
Reason for Change:
Other, please explain:
Member
First Name:
Last Name:
DOB:
Relationship to Subscriber:
Other:
New Physician Name:
Reason for Change:
Other, please explain:
Member
First Name:
Last Name:
DOB:
Relationship to Subscriber:
Other:
New Physician Name:
Reason for Change:
Other, please explain: