Change of PCP Form for TRS Employees - Scott & White Health Plan

Items in RED are 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:

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