MCO Member Address Change Report Form

Person reporting change

FIRST NAME

LAST NAME

CALLER'S PHONE NUMBER

RELATIONSHIP TO MEMBER

EXPLAIN RELATIONSHIP TO MEMBER

MCO

MCO representative completing the form

FIRST NAME

LAST NAME

DATE CHANGE REPORTED

Have you already reported this address change to your eligibility (county/MinnesotaCare/tribe) worker?

Yes

Member information

FIRST NAME

LAST NAME

DATE OF BIRTH

PMI (not required if SSN provided)

SOCIAL SECURITY NUMBER (not required if PMI provided)

CASE NUMBER

SSN (value, hidden, bound to schema)

Are you moving out of the state of MN?

Yes

Is this a permanent move?

Yes

STOP and refer to the contact list. Direct members to call their county worker, tribal worker, or MinnesotaCare office.

What is your new residential address?

DATE OF MOVE (MM/DD/YYYY)

STREET ADDRESS

ADDRESS LINE 2 (Apt. Trailer, Suite)

CITY

STATE

ZIP CODE

COUNTY

PHONE NUMBER

PHONE TYPE

EMAIL ADDRESS

Is there a different address you use for mail where we should send your notices?

Yes

What is your mailing address?

STREET ADDRESS

ADDRESS LINE 2 (Apt. Trailer, Suite)

CITY

STATE

ZIP CODE

EFFECTIVE DATE (MM/DD/YYYY)

Are any other people in the household moving to the new address?

Yes

First name	Last name	Date of birth

For households that have any member with Medical Assistance coverage choose the county they lived in prior to moving. For households that do not have a member with MA coverage, but have at least 1 member with MinnesotaCare coverage, choose MinnesotaCare operations.

NPI/UMPI

ADDITIONAL NOTES (Any clarifications for eligibility worker)