Physician Selection Change Form - Group Health Provider

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PHYSICIAN SELECTION / CHANGE FORM

One of the advantages of being a Group Health Cooperative or Group Health Options, Inc. member is that you get to choose

your own personal physician. Doing so is important. This is the person who is in the best position to coordinate your care.

Please use this form or go online to

to select or change the personal physician for yourself and each family member.

Remember, each family member can select his/her own personal physician.

To get a list of physicians in your area,

visit

or call Customer Service at

1-888-901-4636

Current

patient?

Social Security number

Sex

Name of personal physician

Last name

First name

or member number

M/F

Birth date

Last name

First name

YES

SUBSCRIBER

SPOUSE/DOMESTIC PARTNER

DEPENDENT

If this is a change, please indicate reason: ____________________________________________________________________________________________________________________________

Signature ______________________________________________________________________

Date _________________________________________________________________________

Please mail this form to:

Group Health Cooperative

Physician Selection

P.O. Box 34590

Seattle, WA 98124-9708

Or fax to: 1-888-874-1765

42GG-2011-07W