Change the Role (PCP or Specialist) of a Current Provider Please complete the following information to change a participation provider's role (PCP or Specialist) at their affiliated location.Effective Date* MM slash DD slash YYYY Group/Entity NPI* Group/Entity Name* Group/Entity TIN* Provider NPI* Provider Name* Primary Specialty* Secondary Specialty Emergency/Urgent Care Provider*Emergency/Urgent Care Provider *YesNoPractice Name* Practice NPI (if applicable) Practice Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Practice Phone*Current role at this location*Current role at this location *PCPSpecialistNew role at this location*New role at this location *SpecialistNew role at this location*New role at this location *PCPSpecialty* Name of Provider Assuming Panel* Provider NPI* Is the provider accepting new patients at this location?*Is the provider accepting new patients at this location? *YesNoProvider's hours at this location* Sunday Monday Tuesday Wednesday Thursday Friday Saturday Sunday Hours*Sunday Hours *CustomOpen 24 HoursSunday Open* : Hours Minutes AM PM AM/PM Sunday Close* : Hours Minutes AM PM AM/PM Monday Hours*Monday Hours *CustomOpen 24 HoursMonday Open* : Hours Minutes AM PM AM/PM Monday Close* : Hours Minutes AM PM AM/PM Tuesday Hours*Tuesday Hours *CustomOpen 24 HoursTuesday Open* : Hours Minutes AM PM AM/PM Tuesday Close* : Hours Minutes AM PM AM/PM Wednesday Hours*Wednesday Hours *CustomOpen 24 HoursWednesday Open* : Hours Minutes AM PM AM/PM Wednesday Close* : Hours Minutes AM PM AM/PM Thursday Hours*Thursday Hours *CustomOpen 24 HoursThursday Open* : Hours Minutes AM PM AM/PM Thursday Close* : Hours Minutes AM PM AM/PM Friday Hours*Friday Hours *CustomOpen 24 HoursFriday Open* : Hours Minutes AM PM AM/PM Friday Close* : Hours Minutes AM PM AM/PM Saturday Hours*Saturday Hours *CustomOpen 24 HoursSaturday Open* : Hours Minutes AM PM AM/PM Saturday Close* : Hours Minutes AM PM AM/PM Additional Information Required to Process PCP Role Change RequestName of Provider assuming panel* Provider NPI* Specialty (Must match the provider's PCP role)* Details for the person submitting the formName* Title* Phone Number*Email* Date* MM slash DD slash YYYY CAPTCHA