ERS 2012 - Select PCP

State of Texas and Higher Education
Employees, Retirees, and their Dependents

Scott & White Health Plan
Select or Change Primary Care Physician (PCP)

Scott & White is now an Open Access HMO. A member can go to any network provider without a referral. Members may choose a network primary care physician (PCP) if they would like to designate one, but PCPs are no longer required by the Scott & White Health Plan.

PY2012

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Subscriber's Information

Subscriber's Contract Number: *

(The first nine digits on your medical card.)

Subscriber's First Name: *

Subscriber's Last Name: *

Subscriber's E-Mail:

Member Information

Please enter new primary care physician information for one or more members below. Click to expand the form to enter information for members 2 and 3.

Member's First Name: *

Member's Last Name: *

Member's Date of Birth: *

Relationship to Subscriber: *

Other:

New Physician Name: *

Member 2 Information

Member 2 First Name:

Member 2 Last Name:

Member 2 Date of Birth:

Relationship to Subscriber:

Other:

New Physician Name:

Member 3 Information

Member 3 First Name:

Member 3 Last Name:

Member 3 Date of Birth:

Relationship to Subscriber:

Other:

New Physician Name:

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Scott & White Health Plan

ERS 2012 - Select PCP

ERS PY2012

Scott & White Health PlanSelect or Change Primary Care Physician (PCP)

Scott & White Health Plan
Select or Change Primary Care Physician (PCP)