Medical Renewal Form printable pdf download

Medical Renewal Form

Program: Branch: Case number:

Worker ID:

Case name:

Date of request:

Please return by this date:

It’s time to renew your medical benefits.

• We need to get information from you to see if you are still eligible. You can call

us with this information or return this form.

• Please let us know if you have questions about this form or if you need help or

more time to get proof. Call the number at the top of the page. You may call

collect, if necessary.

If we do not hear from you by

, your medical benefits will end. We

will send you another notice before ending medical benefits.

We will complete a review of medical benefits for:

DOB:



When you see this arrow, it means you may have to send in a document that

shows us the information you gave is correct. For instance, we will need proof of

income and pregnancy.

Please send any needed proof to the address listed at the top of this page.

Does your partner, spouse, a family member or someone you live with make you

afraid by threatening, yelling or physically hurting you or your children?

 Yes

 No

Need help?

Please call your worker. The phone number is at the top of the first page.

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OHA 0945 (06/12)

Medical Renewal Form