Form 295W PDF Details

All Alabama Medicaid recipients must report any changes in their circumstances using the 295W form, an essential document designed by the Alabama Medicaid Agency. This form serves as a comprehensive tool for individuals to communicate various changes, including but not limited to those related to marital status, family composition, income, expenses, and insurance coverage. Importantly, the form not only asks for updates in marital status—detailing specifics such as the spouse's name, Social Security Number (SSN), Date of Birth (DOB), and address—but also covers changes in the household, like the birth of a baby or someone moving in or out. Updates about income alterations, whether it be new income sources or the loss of income, are critical pieces of information that need to be meticulously reported to ensure that Medicaid coverage reflects current needs and circumstances. Additionally, the form offers a section for reporting changes in expenses, notably day or night care payments which directly affect the financial assessments for Medicaid eligibility. Moreover, it includes a straightforward process for reporting insurance changes through a separate specified form and allows for the reporting of a recipient's or another household member's death. Encompassing a vast array of personal life changes, the Form 295W is a crucial component in managing one’s Medicaid coverage effectively, ensuring that recipients and the agency maintain up-to-date and accurate information. Implicit in this process is the commitment to integrity and honesty, as evidenced by the requirement for the recipient's signature under penalty of perjury, affirming that all information provided is true and correct. This process facilitates accurate administration of benefits and supports the goal of providing necessary medical coverage to those in need.

QuestionAnswer
Form NameForm 295W
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesAlabama, medicaid change address, medicaid change of information form, how to change address on medicaid

Form Preview Example

Alabama Medicaid Agency’s Recipient Change Report Form

Name_________________________________________________________

MEDICAID #______________

 

Address_______________________________________________________

Home Phone____________________

City/County/State/Zip________________________________________

Other Phone____________________

Is this a new address? Yes

No If Yes, Date Moved_______________________________________

Check the items that you have changes for. (There are more items listed on the back of this form.) NOTE: Your signature is required on the back of this form.

Marital Status Changes. Date of change_________________________

 

New marital status:

Married

Divorced

Separated

Widowed

If you checked Married, please complete the following:

 

 

Name of Spouse_____________________________________________________________________________

Spouse’s SSN__________________________

Spouse’s DOB____________________________________

Spouse’s Address___________________________________________________________________________

City, State, Zip________________________________________________

Phone____________________

Sponsor Address and Phone Changes. Date of change _________________________

New Sponsor Address_______________________________________________________________________

City, State, Zip_________________________________________ Phone__________________________

NOTE: To change your sponsor to another person, you will need to complete a Form 202 and mail to your caseworker or call 1-800-362-1504 to request a Form 202 be mailed to you.

Family Changes. Date of change _________________________

I Had a Baby. Baby’s Name is_______________________________________

Baby’s SSN_______________________________________

Male Female

Baby was Born on___________________(date) in ______________________________(city/state/zip)

Someone in My Household is Having a Baby. Her Name is______________________________

Date Baby is Due____________________ Number of Babies in Pregnancy__________________

Person(s) Moved Into My Home. Date of change _________________________

Name

Relationship

to You

Income

Date of

Birth

SSN

Receiving

SSI, Yes/No

Person(s) Moved Out of My Home. Date of change _________________________

Name

Relationship

to You

Income

Date of Birth

SSN

Form 295w (03/2009)

Alabama Medicaid Agency

Income Changes. Date of change __________________________

New Income.

Name

Employer Name

Gross Amount

Hourly

Hours

How

Day

 

and Address

of Pay (before

Pay

Worked

Often

Paid

 

 

deductions)

Rate

a Week

Paid

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Attach verification of income.)

Loss of Income. Person Who No Longer Has Income is__________________________________

Date of Last Pay Received_____________________.

Expense changes. Date of change ___________________________________

I Now Pay for Day/Night Care.

Name of Person Who Pays_______________________________________________________________

Name and Age of Person(s) in Care_______________________________________________________

Amount Paid______________________________ How Often________________________________

I No Longer Pay for Day/Night Care.

Insurance Changes. Complete the “Report Insurance Coverage Change Form” which is located on the Medicaid Website at www.medicaid.alabama.gov.

Report of Death.

Name of Recipient_________________________________ Date of death_________________________

I wish to close my Medicaid case. Date _________________________

Reason for closing case _____________________________________________________________________

I wish to withdraw my application. Date _________________________

Other Changes. Date of change_________________________

Explain__________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

By checking this box, I declare under penalty of perjury, that the information I have entered

is true and correct.

_____________________________________________________________

_______________________________

Signature of Recipient

 

 

Date

____________________________________________________________

______________________________

Person Helping to Fill Out Form

 

 

Daytime Phone Number

I am an Application Assister

Yes

No

 

You may E-mail this form by clicking on: changes@medicaid.alabama.gov.

How to Edit Form 295W Online for Free

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Completing this PDF demands attention to detail. Make certain all necessary blank fields are filled out properly.

1. Whenever completing the Assister, make certain to incorporate all of the essential blank fields within the associated part. It will help to hasten the work, allowing for your details to be processed promptly and correctly.

Step # 1 in filling out Alabama

2. Given that the previous array of fields is completed, you need to include the essential specifics in cid Sponsor Address and Phone, New Sponsor Address, City State Zip Phone, NOTE To change your sponsor to, mail to your caseworker or call, cid Family Changes Date of change, cid I Had a Baby Babys Name is cid, Babys SSN, Baby was Born ondate in, cid Someone in My Household is, Date Baby is Due Number of Babies, cid Persons Moved Into My Home, Name, Relationship, and Income so you can progress further.

Alabama completion process clarified (part 2)

Be really attentive when filling in cid Family Changes Date of change and Relationship, since this is the part in which most users make errors.

3. This subsequent segment is fairly straightforward, cid Persons Moved Out of My Home, Date of Birth, Relationship, Income, SSN, to You, Form w, and Alabama Medicaid Agency - each one of these blanks will have to be filled in here.

Form w, SSN, and Relationship of Alabama

4. This next section requires some additional information. Ensure you complete all the necessary fields - cid Income Changes Date of change, cid New Income, Name Employer Name, Gross Amount Hourly Hours, How, Day, and Address, of Pay before Pay Worked, Often Paid, deductions Rate a Week, Paid, Attach verification of income, cid Loss of Income Person Who No, Date of Last Pay Received, and cid Expense changes Date of change - to proceed further in your process!

Often Paid, Paid, and cid Loss of Income Person Who No inside Alabama

5. The form needs to be completed by filling in this area. Here you can find a detailed list of blanks that have to be completed with accurate details to allow your document usage to be faultless: cid Insurance Changes Complete the, located on the Medicaid Website at, cid Report of Death, Name of Recipient Date of death, cid I wish to close my Medicaid, Reason for closing case, cid I wish to withdraw my, cid Other Changes Date of change, Explain, cid By checking this box I declare, and is true and correct.

Filling out part 5 of Alabama

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