MIT SHIP: Choose a PCP

Your PCP—either a physician or a nurse practitioner—will be the clinician you see for most of your care and with whom you’ll discuss your health concerns and questions. (See “What’s a PCP?”)

You are not required to choose a PCP, but an MIT Medical PCP can help to coordinate the care you receive at MIT Medical and elsewhere. And don’t worry; if you change your mind about your PCP choice, it’s easy to switch.

I am filling out this form for:

Are you an MIT Student?

Is your child an MIT student?

Is your spouse or partner an MIT student?

Name:

Email:

Phone number:

Date of birth:

Child’s name:

Child’s date of birth:

Child’s phone number:

Your name:

Your email:

Your phone number:

Spouse’s or partner’s name:

Spouse’s or partner’s date of birth:

Spouse’s or partner’s phone number:

Your name:

Your email:

Select a primary care provider (PCP)

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MIT SHIP: Choose a PCP

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