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REQUEST A NEW ID CARD

If you have not received your Member ID card or you have lost your Member ID card, please send the following information with your request so that we may help you.  It will take 7 - 10 days before you get your new ID card.

* = Required Information

*Medicaid ID# (on card):

*Members First Name:

*Members Last Name:

*Date of Birth:

*Address:

*City:

*State: *Zip Code:  *Phone Number:

*Email Address:

 

*Request New ID Card:  Please Choose:

Lost ID Card: 

Damaged ID Card: 

Stolen ID Card:  

Never Received ID Card:   

*Comments:

 

*Person Sending E-Mail:

*First Name: *Last Name:

*Relationship:

*How can we contact you?: