Thank you!

If you need immediate assistance, please contact Member Services or Provider Services at 1-866-329-4701 (TTY: 711).

PLEASE NOTE: If you completed this form on behalf of someone else, don't forget to provide documentation showing the authority to represent the member if it was not submitted previously. Representatives include family members, friends, caregivers or providers who the member authorized in writing or others legally able to act on behalf of the member, such as someone who holds power of attorney or the member's legal guardian. You can mail, fax or email the documentation directly to us. You can find all our contact information on our Contact us page.