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Primary Care Provider Change

Online Form


Contra Costa Health Plan
595 Center Avenue, Suite 100
Martinez, CA 94553
877-661-6230

To change your Primary Care Provider, please use the Online Form below then Submit.

Note: all fields must be completed.

/ /
Sex: Male     Female
Home:

Cellphone:

Please choose from the List of Providers who are accepting new patients this month.
Once you have made your selection, complete the section below. If you need to change Primary Care Providers for other members of the family, complete separate requests for each person.
For Medi-Cal members requesting a change to Kaiser Services you must have been a member of Kaiser within the past 12 months or meet one of the other criteria and include your Kaiser Member Identification Number
Note: when your request is processed you will receive email confirmation.

Provider FIRST Name:

Provider LAST Name:
I want the same PCP for all my children.
I want the PCP I have seen before.
I want a PCP closer to home or other location.
I want a PCP to meet certain needs or preferences I have (e.g., language, ethnicity, gender).
I am not happy about the service or treatment I received from my currently assigned PCP.
I am having trouble getting an appointment from my currently assigned PCP.
I want to choose my own PCP for other reasons.
Kaiser ID:

Relationship to member:

Contra Costa Health Services (CCHS) uses automated calls to tell people about important health-related services & benefits or changes to your healthcare coverage. Your information is kept private and secure.
Members or parents / guardians of minors completing this online form agree to allow Contra Costa Health Services (CCHS) to communicate with you in this way.
(Note: This is especially important for Kaiser assignment requests. It's the easiest way to get a status update.)
Members who do not want to provide consent may call Member Services to change their PCP.


If this form was not completed by member or member's legal guardian, we will be unable to process request without member's explicit agreement.