MFP Participant - dch georgia 2025

1. Click ‘Get Form’ to open the MFP Participant Enrollment Status Change Form in the editor.
2. Begin by entering the participant's first and last name, Medicaid number, date of birth, and phone number in the designated fields.
3. Provide an alternative contact name and the date of discharge from the nursing facility or institution.
4. Select the type of status change related to MFP participation and fill in the new address along with any additional phone numbers if applicable.
5. If enrollment has ended, check the appropriate reason from the list provided. If re-institutionalized, indicate the reason as well.
6. For participants who have moved or are being re-enrolled, specify their new residence type and whether they live with family members.
7. Finally, complete your details as an MFP facilitator including your name, region/office, phone number, and email before submitting.

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