CCHP
En Español

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 using this link : www.cchp.prismisp.com
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 and include your Kaiser Member Identification Number
Note: when your request is processed you will receive email confirmation.

Provider FIRST Name:

Provider LAST Name:
Kaiser ID:

Relationship to member:

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.