ODS. Healthcare from your head to your toes.

Member change form

Please complete the information related to your changes and "submit" this form. With this form you can:

Request an ID card
Change your address
Change your PCP.

Changes regarding:	Medical coverage Dental coverage Medical and dental coverage
Name*:
Subscriber ID*:
or birthdate*:	00-00-0000
For authentication purposes, at least one field below is required*:
E-mail address:
Telephone number:	111-111-1111

Request ID card

Change address
Enter former address:
Street:
City:	State: ZIP:
Enter new address:
Street:
City:	State: ZIP:
Important - If you have group coverage, notify your employer regarding your new address.

Change PCP:
Steps to selecting a new PCP:
View our directories to choose a new PCP on your plan's network. Contact your new PCP's office to ask if they will accept you as a patient; some offices do not accept new patients. Remember your new PCP is effective at the beginning of the next month. You may change your PCP up to two times per year.
Full name of new PCP(s):	Full name of member(s) changing PCPs:	Established patient
PCP	for	Yes No
PCP	for	Yes No
PCP	for	Yes No
PCP	for	Yes No

Comments:

*Required fields

Disclaimer
E-mail is not a secure method of transmission. If you prefer, you can reach us by telephone or mail. ODS will respond to your inquiry within 24 to 48 hours, excluding weekends and holidays.