BCMH Notification of Changes in Child/Family Status Form

Client Information

Client Name

First

Last

Date of Birth

New Address (if applicable)

City

State/Province

Zip/Postal

Country

Does this involve a move to a different county of residence?

Yes

No

Name of New County:

Phone of Client/Parent/Guardian:

Effective Date (If new phone or new address)

New/Current Insurance Information For The Client

Name of Insurance Company

Phone Number

Name of Insured:

First

Last

Effective Date

Policy Number

Group Number

Does your plan include prescription benefits:

Yes

No

N/A

Does your drug plan require mail order pharmacy:

Yes

No

N/A

Name of company that administers prescription benefits: (If Applicable):

Does client have dental insurance:

Yes

No

Does client have vision insurance:

Yes

No

Name of company that administers dental benefit:

Name of company that administers vision benefit:

Change in Medicaid Status

Check Correct Line

Approved

Denied

No Longer Eligible

N/A

Case #:

Date

Reason:

Date

Name of Medicaid HMO Insurance (if applicable):

Changes in Family Status (If Applicable)

Parent/Guardian name change, change in guardianship, etc:

BCMH Notification of Changes in Child/Family Status Form

Client Information

New/Current Insurance Information For The Client

Change in Medicaid Status

Changes in Family Status (If Applicable)

Office

Hours/Clinics

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