Address Change Form

Residence address
Member's Name
Social Security Number	(no dashes)
Current Health Plan	PacificSource Kaiser Permanente Moda Health (formerly ODS Health) Providence
	Old	New
Street Address
City, State, Zip
County
Mailing address (if different)
	Old	New
Street address
City, State, Zip
County

Phone number

Are you moving outside of the service area of your current health plan? If yes, you must terminate your current health plan, and enroll in a health plan that offers coverage in your new area. A link to the form will be provided after you submit your change of address request.
Yes No

Authorization

I understand that my signature (or the signature of the person authorized to act on behalf of the individual under the laws of the State where the individual resides) on this form means that I have read and understand the contents of this form. If signed by an authorized individual (as described above), this signature certifies that: 1) this person is authorized under State law to complete this form and 2) documentation of this authority is available upon request.

	Member's Signature (Type name)
	Date
	Power of Attorney Signature (Please submit a copy of the Power of Attorney if the Attorney is signing for the member.)
	Date