Fillable Alabama Medicaid Agencys Recipient Change Report Form (State of Alabama)

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Alabama Medicaid Agencys Recipient Change Report Form (State of Alabama)

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The Alabama Medicaid Agencys Recipient Change Report Form (State of Alabama) form is 2 pages long and contains:

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  • 16 check-boxes
  • 89 other fields

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File type: PDF

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Alabama Medicaid Agency’s Recipient Change Report Form
Name SSN/Medicaid #
Address Home Phone
City/County/State/Zip Other Phone
Is this a new address?  Yes  No If Yes, Date Moved
Check the items that you have changes for. (There are more items listed on the back of this form.)
NOTE: Your signature is required on the back of this form.
Marital Status Changes. Date of change_________________________
New marital status:  Married  Divorced  Separated  Widowed
If you checked Married, please complete the following:
Name of Spouse ____________________________________________________________________
Spouse’s SSN__________________________ Spouse’s DOB ___________________________
Spouse’s Address __________________________________________________________________
City, State, Zip ____________________________________________ Phone _______________
Sponsor Address and Phone Changes. Date of change _________________________
New Sponsor Address _______________________________________________________________
City, State, Zip ____________________________________ Phone ______________________
NOTE: To change your sponsor to another person, you will need to complete a Form 202 and mail to your
caseworker or call 1-800-362-1504 to request a Form 202 be mailed to you.
Family Changes. Date of change _________________________
I Had a Baby. Baby’s Name is______________________________  Male  Female
Baby’s SSN_______________________________________
Baby was Born on________________(date) in ________________________(city/state/zip)
Someone in My Household is Having a Baby. Her Name is_____________________
Date Baby is Due________________ Number of Babies in Pregnancy______________
Person(s) Moved Into My Home. Date of change _________________________
Name Relationship
to You
Income Date of Birth SSN Receiving SSI,
Yes/No
Person(s) Moved Out of My Home. Date of change _________________________
Name Relationship
to You
Income Date of Birth SSN Receiving SSI,
Yes/No
Form 295 (1-7-14) Alabama Medicaid Agency
Income Changes. Date of change __________________________
New Income.
Name Employer Name
and Address
Gross Amount
of Pay (before
deductions)
Hourly
Pay Rate
Hours
Worked a
Week
How
Often
Paid
Day Paid
(Attach verification of income.)
Loss of Income. Person Who No Longer Has Income is___________________________
Date of Last Pay Received_____________________.
Insurance Changes. Complete the “Report Insurance Coverage Change Form” which is located on the
Medicaid Website at www.medicaid.alabama.gov
Report of Death.
Name of Recipient______________________________ Date of death____________________
I wish to close my Medicaid case. Date _________________________
Reason for closing case ____________________________________________________________
I wish to withdraw my application. Date _________________________
Other Changes. Date of change_________________________
Explain____________________________________________________________________________
____________________________________________________________________________________
By checking this box, I declare under penalty of perjury, that the information I have entered is true and correct.
_____________________________________________________________
Signature of Recipient Date
_______________________________________________________________
Person Helping to Fill Out Form Daytime Phone Number
I am an Application Assister  Yes  No
You may Fax this form to 334-353-5689, or Mail to: Alabama Medicaid Agency, Attn: Eligibility Change Unit, 501
Dexter Avenue, P O Box 5624, Montgomery, AL 36103-5624. You may also email the form to
changes@medicaid.alabama.gov
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Alabama Medicaid Agencys Recipient Change Report Form (State of Alabama)

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Completed 9 September 2020

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