Medicaid Member Contact Form

Name:* Phone Number:* Issue*

- Select - - Select - Question on pharmacy or prescription benefits Question on member benefits Question on member eligibility Question on member ID Card Request to change Primary Care Physician Request for list of participating providers All other requests or questions

Best time to contact you?:

- None - Morning: 8am - 10am Noon: 10am - 2pm Afternoon: 2pm - 4pm

May a representative call you to discuss this issue.: * Yes, a representative may call me to discuss this issue.

I am over 13 years old. Under the Children’s Online Privacy Protection Act (COPPA) of 1998 Gateway Health Plan^® can only accept information from individuals over the age of 13.: * I am over 13 years old

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