Medicaid Change Reporting Form
Report changes in your Medicaid household, contact details, income, address, or other case information so the agency can review your case.
Reporter Information
Full Name
*
First Name
Middle Name
Last Name
Relationship to Medicaid Case
*
Please Select
Self
Spouse/Partner
Parent/Guardian
Child
Other
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Preferred Contact Method
*
Phone
Email
Mail
Medicaid Case Information
Household or Case Member Name
*
Medicaid Case Number or Member ID
County or State Agency Office
*
Please Select
County Office
State Agency Office
Other
Does this change apply to the whole household or only specific member(s)?
*
Whole household
Specific member(s)
Change Details
Type of Change
*
Household composition
Address
Income
Employment
Pregnancy
Birth/Adoption
School status
Other coverage
Disability/Health status
Other
Effective Date / Date of Change
*
-
Month
-
Day
Year
Date
Is this change already in effect?
*
Yes
No
Describe the change and who is affected
*
Household Members Affected
Affected Household Members
*
Which members were affected?
Reporter
Spouse/Partner
Child
Parent
Sibling
Other Relative
Non-Relative
Other
Describe the change for each affected member
*
Supporting Details and Follow-up
Supporting documents
Upload a File
Drag and drop files here
Choose a file
Cancel
of
May we contact you for clarification if needed?
*
Yes
No
Confirmation
*
I confirm that the information provided is true and complete to the best of my knowledge.
Submit Change Report
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