CP&P 11-69
(new 6/2009)
OFFICE
Location/Code
Person Sending
Phone Number
Medicaid Eligibility File Demographic Changes
To: ITR Medicaid Unit
<dcfitrmedicaid@dcf.state.nj.us>
7/27/2016 - 9:28 PM
The purpose for the change is for:
Correction
Adoption
KLG
- Child's name as it should appear:
- NJ SPIRIT Case ID Number:
- NJ SPIRIT Person ID Number:
- Date of Birth:
- Sex:
- Race:
- Social Security Number:
- Medicaid Number:
- Child's name as it previously appeared:
- NJSPIRIT Case ID Number:
- NJSPIRIT Person ID Number:
- Date of Birth:
- Sex:
- Race:
- Social Security Number:
- Medicaid Number (when applicable):
- Child's HMO Information (if applicable)
- Adoptive Parent/Kinship Legal Guardian
does /
does not wish to continue HMO
- Name of HMO:
- Previously closed effective date:
- Reopen effective date:
If other than 1st day of following month - Documentation Required for Back Dated Request
NOTES: