Form 295w - Alabama Medicaid Agency'S Recipient Change Report Form
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2Alabama Medicaid Agency’s Recipient Change Report Form
Medicaid #______________
Name_________________________________________________________
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
Income
Date of
SSN
Receiving
to You
Birth
SSI, Yes/No
Person(s) Moved Out of My Home. Date of change _________________________
Name
Relationship
Income
Date of Birth
SSN
to You
Form 295w (03/2009)
Alabama Medicaid Agency
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