Medicaid And Kid Care Chip Renewal Form
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Medicaid and Kid Care CHIP
or in large print or another way that’s best for you.
Renewal Form
Call 1-855-294-2127 (TTY/TDD: 1-855-329-5204).
[Date]
[PI name]
Respond by: [Due Date]
[Address]
[city, ST zip]
It is time to renew your Medicaid or Kid Care CHIP coverage.
You can renew
Renew online! Go to
your Medicaid or
By phone: Just call 1-855-294-2127 (TTY/TDD: 1-855-329-5204). The call is free.
Kid Care CHIP
By mail: Complete this form and mail it to our customer service center:
coverage in any
2232 Dell Range Blvd., Suite 300
Cheyenne, WY 82009
one of these ways
By fax: 1-855-329-5205
In person: Visit our office at 2232 Dell Range Blvd., Ste. 300, Cheyenne, WY 82009.
Office hours are 7:00 a.m. to 6 p.m. Monday to Friday
1. Answer all of the questions on the form.
How to complete
2. Read the information about you and each member of your household. Add any
this renewal form
missing information. If any information has changed, print the right information. If more
space is needed, please attach additional pages.
3. Sign the form on page 8.
4. Return this form by [DUE DATE]. If you do not return the form by this deadline, you
will lose your Medicaid or Kid Care CHIP coverage.
We need information about each person living in your household or listed on your
What we need
tax return, including:
those who get Medicaid or Kid Care CHIP now,
those who do not get Medicaid or Kid Care CHIP now but would like to apply, and
others who do not want to apply.
We will check your answers using information from computer data sources, including the
Internal Revenue Service (IRS), the Social Security Administration, and the Department of
Homeland Security. If the information does not match, we may ask you to send more
information.
If you do not qualify for Medicaid or Kid Care CHIP, your information may be
If you do not qualify
forwarded to another program so they can see if you qualify.
for Medicaid
?
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Questions?
Call our customer service center at 1-855-294-2127 (TTY/TDD: 1-855-329-5204).
The call is free. You can call 7:00 a.m. to 6:00 p.m. Monday to Friday. Or visit .
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