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Member Transfer Request

For member use only. Providers are prohibited from submitting member transfer requests. All transfers are effective the same day of the request.

Step 1: Search for Provider Office

Search Criteria

Step 2: Select Provider Office to be Assigned

Dentist NameOffice LocationMore InfoSelect

Step 3: Enter Member Details

OFFICE DETAILS


MEMBER DETAILS

Yes

Success Error

By clicking “Submit”, I affirm that I am a member of Kalos I acknowledge that use of this form by anyone other than the member named above is considered potentially fraudulent and may be subject to corrective action by the Plan.

Please only click Submit once