Model Medicaid Renewal Form

It is time to renew your Medicaid coverage.
You can renew your
Medicaid in any
one of these ways
Renewing online is faster! Go to <web address> and click on Renew My Medicaid
By phone: Just call 1-800-XXX-XXXX (TTY: 1-888-XXX-XXXX). The call is free.
By mail: Complete this form and mail it to:
[Medicaid Agency]
[100 State Street]
[Anycity, State]
In person: Visit our office at [Medicaid Agency] [100 State Street] [Anycity, State].
Office hours are 8:30 a.m. to 5 p.m. Monday to Friday, and 9:00 a.m. to 12 p.m. on
How to complete
this renewal form
Answer all of the questions on the form.
Read the information about you and each member of your household. Add any
missing information. If any information has changed, write in the right information.
Sign the form on page 9.
Return this form by December 12, 2013. If you do not return the form by this
deadline, you will lose your Medicaid coverage.
What we need
We need information about each person living in your household or listed on
your tax return, including:
those who get Medicaid now,
those who do not get Medicaid now but would like to apply, and
others who live in the household and do not get Medicaid but do not want to apply.
We will check your answers using information from computer data sources,
including the Internal Revenue Service (IRS), the Social Security Administration,
the Department of Homeland Security and others. If the information does not
match, we may ask you to send more information.
If you do not qualify
for Medicaid
If you do not qualify for Medicaid, [state agency] will check to see if you qualify
for other kinds of health coverage. [State agency] may send your information to
another program so they can see if you qualify.
You can get this notification in another language
or in large print or another way that’s best for you.
Call 1-800-XXX-XXXX (TTY: 1-888-XXX-XXXX).
Renewal Form
Mary Smith
123 Smith Street
Smithtown, FL 00000
November 5, 2013
Respond by: December 12, 2013
Letter number: 34567
Questions? Call [state agency] at 1-800-XXX-XXXX. The call is free. (TTY: 1-888-XXX-XXXX).
You can call [days and hours of operation]. Or visit <web address>.
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