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REQUEST MEMBER MATERIALS

If you are unable to find your First Coast Advantage Member Materials,  please send the following information with your request so that we may help you in your search.

* = 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 Member Materials:  Please Choose:

Member Handbook English / Member Handbook Spanish: 

Provider Directory: 

Change of Address Form:

Medical Release Form:  

Notice of Privacy Practices:   

Universal Enhance Benefit Form English / Enhanced Benefit Form Spanish: 

Other: 

*Comments:

 

*Person Sending E-Mail:

*First Name: *Last Name:

*Relationship:

*How can we contact you?: