Bhsf Form 2-L (Nf) - Medicaid Renewal Form For Nursing Home/group Home Care
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9Renewal Month:
BHSF Form 2-L (NF)
Medicaid Renewal Form
Rev. 06/11
Prior Issue Obsolete
CSLD/WKR:
for Nursing Home/Group Home Care
Return this form or call us by:
Use this form to renew Medicaid coverage for the person in the nursing home or group home. If you do
not renew, medical coverage will end. You may renew by mail, phone, fax, or in person. After we hear
from you, we will let you know if they still qualify.
How to Renew
By mail: Fill out and sign this form. Return the form and needed documents (see page 6) in the envelope
provided. If you need extra space for any question, use a separate sheet of paper.
By phone: Call the worker who sent you this form. You may also call (toll-free) 1-888-342-6207 Monday
through Friday, 8:00 A.M. to 4:00 P.M. Press 1 for English and then 0 for an operator who will transfer you to
your worker. You must speak to your worker to renew by phone. If you are deaf or hard of hearing and have a
TTY text telephone, call 1-800-220-5404.
By fax: Fill out and sign this form. Fax it and needed documents (see page 6) to the fax number on the letter that
came with this form. If you need extra space for any question, use a separate sheet of paper.
In person: Visit your closest Medicaid office. The address to your local Medicaid office is on the letter that
came with this form.
–
START HERE
Please use a black ink pen.
What language do you speak best?
English
Spanish
Vietnamese
Other (specify)
What language do you write best?
English
Spanish
Vietnamese
Other (specify)
1. Person Getting Medicaid
Name
Date of Birth
First
Middle Initial
Last
Social Security Number
Medicare Claim Number
Name of Nursing Home or Group Home
Parish
2. Who takes care of this person’s business affairs? They Do – Go to Question 3 I Do –
Fill Out Below
Your Name
Mailing Address
Apt/Lot
City
State
Zip
Daytime Phone Number (
)
Cell Phone Number (
)
E-mail Address
Best Day and/or Time for Us to Call You During Our Office Hours (8:00am-4:30pm, Monday - Friday)
Do you have Power of Attorney? Yes No Are you the Curator or Under Curator? Yes No
Questions - Call 1-888-342-6207
(TTY text telephone for deaf and hard of hearing: 1-800-220-5404)
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