2017 idaho change address form fill-2026

1. Click ‘Get Form’ to open the 2017 Idaho Change Address Form in our editor.
2. Begin by entering the participant's first, middle, and last name along with their Medicaid number. This information is crucial for identification.
3. Fill in the new physical address and mailing address fields, ensuring that you include the city, state, and zip code for both addresses.
4. Indicate the date when the change of address occurred. This helps maintain accurate records.
5. Select the type of facility from which you are moving and to which you are moving. Check all applicable boxes to provide complete information.
6. Identify who is completing the form by selecting either 'Medicaid Staff' or 'Customer'. Ensure that the appropriate person signs below.
7. Finally, print your name, sign, provide your phone number, and date the form before submitting it via email to mybenefits@dhw.idaho.gov.

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