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Member Transfer Request

OFFICE DETAILS
Office Name
Office ID
Provider Name
Address
Phone #
MEMBER DETAILS
First Name
Last Name
Member Medicaid Number
Member DOB
Member Contact Information (phone number on file)
Office Requested to be Assigned
Apply transfer to all family members under age 18
Provider Offices Only: If you are transfering multiple members, attach list
Attach list with multiple members

Please only click Submit once