Correct/add the following information (check all that apply): change name, add/correct Social Security Number (SSN), correct date of birth, add/change phone number, correct gender information.
Addresses: change residency address, change mailing address, add/change secondary mailing address.
Language read: tell us what language you want your notices sent to you.
Visual disability: we can give you notices in the following formats: large print, audio CD, data CD, Braille.
Provider information: to be completed by providers only. This section is not to be used for Home Care Services Program Providers submissions.
Help: we can help you. Call us at 888-692-6116. You can also ask for help when you visit an HRA office.
| Question | Answer |
|---|---|
| Form Name | MAP-751K |
| Form Length | 2 pages |
| Fillable? | Yes |
| Fillable fields | 73 |
| Avg. time to fill out | 13 min |
| Edition | 11/27/2024 |
| Replaces | MAP-751, MAP-751a, and MAP-3069b |
| Documentation | No documentation required |
| Other names | MAP-751K, MAP751K, MAP 751K, MAP-751k, 751K, Consumer/Provider Request to Change Information on File |
| Official source | MAP-751K (Rev 11/27/2024), |
Map 751K Form isn’t the one you’re looking for?