Contact Information Update Form

Step 1 of 3

This form is for Medicaid members only (ACCESS/MED and TRUST/RHE). Members receiving SSI must report contact information changes directly to the Social Security Administration (SSA). Please check your plan on your Neighborhood Member ID card.

Complete this form to report a change of address, phone number or email address for you and your household members. This form must be filled out by the head of household.
Member Information
Enter Member Id and Date of Birth for the Head of Household before completing the form.
Member ID*
Date of Birth*
MM slash DD slash YYYY
Name*
First Last
Plan Name*
Error Message

Check this box to certify that you are the head of household.*
Check this box to certify that you are the head of household. *
- Yes
- No
Please call Member Services for assistance. They are available Monday - Friday, 8:00am - 6:00pm. They can be reached at 1-800-459-6019. Thank you.
Email
Primary Phone Number
Secondary Phone Number
Other Phone Number
Residential Address*
Street Address Address Line 2 City State ZIP Code
Is the Residential address listed above where you live and receive your mail?*
Is the Residential address listed above where you live and receive your mail? *
- Yes
- No
Do you have a Mailing Address (if it is different from your Residential address)*
Street Address Address Line 2 City State ZIP Code
Can we share your updated information with the State to keep your records current?*
Can we share your updated information with the State to keep your records current? *
- Yes
- No
Review Neighborhood’s Internet Privacy Statement here.
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#3206, Approved 05/17/22

Member Information