State of California—Health and Human Services Agency Department of Health Care Services
CONTACT UPDATE
Please fill in numbers 1 through 4, and sign number 5 below:
1. New Contact Information 2. Old Contact Information
Name (print) Name (print)
Address (number, street, apt.) Address (number, street, apt.)
City State ZIP code City State ZIP code
Mailing address (if different from above) Mailing address (if different from above)
City State ZIP code City State ZIP code
Telephone number Telephone number
( ) ( )
3. Your Health Plan Information 4. Personal Information
Health plan name (print) Your date of birth
Your health plan number Your Beneficiary Identification Card (BIC) number
PLEASE READ THE FOLLOWING BEFORE SIGNING BELOW:
You can help us keep your Medi-Cal contact information current by completing, signing, and turning in this
form. It allows your managed care plan to share with your county Medi-Cal office any name, address,
and/or telephone number changes you make. This form will help in making sure that you receive the most
current information about your Medi-Cal benefits.
The county Medi-Cal office may not be able to update your Medi-Cal case file with your name, address,
and telephone number change if this form is not completed and signed by you. Don’t forget that Medi-Cal
rules require you to report a change of address to the county Medi-Cal office within ten days.
5. PLEASE PRINT YOUR NAME, SIGN, AND DATE IN THE AUTHORIZATION BOX BELOW:
I,
(print name) _________________________________________, give permission for the county Medi-Cal
office to update my Medi-Cal case file and those of my family members with any changes in information
regarding my name, address, and/or telephone number that I report to my managed care plan. I
understand that I will need to complete a new form every time I have a change to my name, address,
and/or telephone number.
______________________________________________________________ _________________________
Signature Date
COUNTY INFORMATION (to be filled in by county staff)
Case number Worker name Worker number Worker telephone number
( )
MC 354 (05/07)
