Are you looking for a convenient and effective way to stay fit and healthy? If so, Silver Sneakers Online Classes may be just what you need. Silver Sneakers is a popular fitness pr... Healthy partnerships are our specialty. With Ambetter, you can rely on the services and support that you need to deliver the best quality of patient care. You’re dedicated to your patients, so we’re dedicated to you. When you partner with us, you benefit from years of valuable healthcare industry experience and knowledge. If you have any questions or need more information on anything, please call us 8 a.m.-5 p.m. We are here for you. 1-844-366-2880 (TTY/TDD 1-844-804-6086) SilverSummit Healthplan welcomes all members and is dedicated to giving you quality care. Learn more about Nevada Medicaid today. Contact us at 1-866-263-8134 and we will work with you (and, if you wish, with your doctor) to find a wellness program with the same reward that is right for you in light of your health status. You will only be able to purchase public transportation directly from the agency either in-person or online. Passes can not be purchased through retail ...Health insurance is an essential aspect of maintaining good health and wellbeing. However, with so many options available, it can be overwhelming to choose the right plan that meet...Renewing Medicaid Benefits Form. The form fields are loading, please wait. SilverSummit cannot process your recertification application. If you have any questions about the renewal process, feel free to call us at: 1-844-366-2880 (TTY/TDD 1-844-804-6086). Update your address information on Nevada Medicaid. DWSS services remain available online ...Ambetter from SilverSummit Healthplan is a Qualified Health Plan issuer in the Nevada Health Insurance Marketplace and does not discriminate on the basis of race, color, national origin, disability,age, sex, gender identity, sexual orientation, or health status in the administration of the plan,including enrollment and benefit determinations.Behavioral Health Forms. For applicable service requests, please include the following clinical documentation: LOCUS/CASII Score and Intensity of Needs Level. Discharge Summaries should be faxed to 1-866-535-6974. Completing an OTR: Tips, Pitfalls & Common Mistakes (PDF) NV Behavioral Health (NBH) Mobile Assessment …Ambetter from SilverSummit Healthplan is a Qualified Health Plan issuer in the Nevada Health Insurance Marketplace and does not discriminate on the basis of race, color, national origin, disability,age, sex, gender identity, sexual orientation, or health status in the administration of the plan,including enrollment and benefit determinations.Our Health Plans; Enroll in a Plan; Find a Doctor or Pharmacy; Plan Benefit Materials; Contact Us; Medicare Resources New Member Guide; FAQs; ... Wellcare By Allwell from Silver Summit Health 2500 N. Buffalo Drive, Ste 250 Las Vegas, NV 89128. HMO: 1-833-854-4766; (TTY: 711) OUTPATIENT MEDICAID. Complete and Fax to: 1-844-367-7022 Transplant Request Fax to: 1-833-414-1503. Your health is more important than anything else. A healthy person can keep earning money so always put your health ahead of your financial needs. Don’t make the mistake of thinkin...Silver Summit Health Plan offers trainings for both behavioral health and physical health providers in our network at no cost. Our team provides mostly clinical, provider-focused education on topics that are geared towards improving member outcomes. ... The majority of our clinical trainings also offer behavioral health continuing education ...As we age, it’s important to stay active and healthy. Silver&Fit® is a fitness program designed specifically for seniors that helps them stay in shape and maintain their health. Si...Wellcare By Allwell from Silver Summit Health 7700 Forsyth Boulevard Clayton, MO 63105. 1-800-977-7522 (TTY: 711) 1-844-796-6811 (TTY: 711)While State Farm is perhaps best known for homeowners insurance, it also offers supplemental health insurance, and you can buy Blue Cross Blue Shield individual medical coverage th...Pharmacy. It's important to SilverSummit Healthplan that our members receive drug therapy that is appropriate, high-quality and cost-effective. We work hard to ensure you have access to safe and effective medications that are medically proven to help you get healthy and stay healthy. We will ensure you have access to safe and effective ...If a member switches health plans, Wellcare By Allwell will send their clinical records (included in the USCDI data set) to another health plan. This is in order to build a complete health record. ... Wellcare By Allwell from Silver Summit Health 7700 Forsyth Boulevard Clayton, MO 63105. 1-800-977-7522 (TTY: 711) 1-844-796-6811 (TTY: 711 ...Ambetter is a Qualified Health Plan (QHP) as defined in the Affordable Care Act (ACA). Ambetter is offered to consumers through the Health Insurance Marketplace, also known as the Exchange. The Health Insurance Marketplace makes buying health insurance easier. The Affordable Care Act is the law that has changed healthcare. The goals of the ACA are:Plan Preferred Drug List and Prior Authorization List . The SilverSummit Preferred Drug List (PDL) describes the circumstances under which contracted pharmacy providers will be reimbursed for medications dispensed to members covered under the program. All drugs covered under the Nevada Medicaid program are available for SilverSummit members.The phone number is 1-844-366-2880, TTY: 1-844-804-6086, Relay 711. There is more information about this later in the handbook. See the “Prior Authorization for Services” section. Some other benefits you can use are telemedicine, telemonitoring and telehealth.Choose the Medicaid plan that gets you dollar rewards to spend at Walmart. When SilverSummit members go to the doctor and do other healthy activities, they earn reward dollars they can spend at Walmart on groceries, clothing, electronics, school supplies, appliances, sports equipment, and other things they need. *Welcome to SilverSummit Healthplan, a dedicated member of the Centene family that has been proudly serving Nevada since 2017. We're not just a health insurance provider - …FROM I silversummit health plan™ Ambetter.SilverSummitHealthplan.com . 2023 Formulary. Effective January 1, 2023Your health is more important than anything else. A healthy person can keep earning money so always put your health ahead of your financial needs. Don’t make the mistake of thinkin...Cardiac Solutions. SilverSummit Healthplan has contracted with National Imaging Associates (NIA), an affiliate of Magellan Health Services, for radiology benefit management. Use the Find A Doctor Tool to search for in-network Medicare doctors, hospitals, pharmacies, and other providers. Consider choosing a doctor or provider that’s in-network. This will help keep your healthcare costs affordable. If you need help finding an in-network doctor or provider, give us a call. In the ever-evolving landscape of healthcare, it is essential for health plans and providers to have efficient systems in place to streamline administrative processes. One such sol... NV Behavioral Health (NBH) Mobile Assessment Authorization (PDF) Behavioral Health Addendum (PDF) Outpatient Prior Authorization Form (PDF) Inpatient Prior Authorization Form (PDF) SilverSummit Healthplan provides tools and support our providers need to deliver the best quality of care for Nevada Medicaid beneficiaries. View our resources. Medicaid Plan. Login; Find a Provider; How to Enroll; Renewing Medicaid Benefits; Benefits and Services; Member Resources; Health & Wellness; Health Insurance Marketplace; Medicare Advantage Plan; For Providers. Become a Provider. Provider Maintenance; Coronavirus Information for Providers. Covid-19 Medicaid Notice Billing Guidelines; Login ...Pharmacy. We are committed to providing appropriate, high-quality, and cost-effective drug therapy to all Ambetter Health members. Use our Preferred Drug List to find more information on the drugs that Ambetter Health covers. 2024 Formulary/Prescription Drug List (PDF) 2023 Formulary/Prescription Drug List (PDF) 90-Day Extended Supply ...This Strategic and investment plan will enable the health sector in Nairobi City County to play its role in the realization of the national objectives outlined in the Economic … Pre-Auth Check. Use our tool to see if a pre-authorization is needed. It's quick and easy. If an authorization is needed, you can access our login to submit online. If you are a Nevada resident, find out if you need a Medicaid pre-authorization with SilverSummit Healthplan's easy pre-authorization check. Wellcare By Allwell from Silver Summit Health 7700 Forsyth Boulevard Clayton, MO 63105. 1-800-977-7522 (TTY: 711) 1-844-796-6811 (TTY: 711)Exercising regularly is one of the best things you can do for your health and wellbeing. But with gym memberships costing hundreds of dollars a year, it can be difficult to fit in ...This form may be photocopied Required Reconsideration/Appeal Form Use this form as part of SilverSummit Healthplan reconsideration/appeal process to address the decision made during thecodes can minimize the administrative burden on providers and health plans by greatly decreasing the need for medical record review. Encounters vs Claim An encounter is a claim which is paid at zero dollars as a result of the provider being prepaid - or capitated for the services he/she provided our members. For example; if you are the PMP Our Benefits. Better Coverage. Better Perks. Ambetter Health is on a Mission for Better, and that means better coverage and better perks for you. Beyond great everyday benefits like Virtual 24/7 Care*, members have access to exclusive programs like My Health Pays®** and Ambetter Perks. We’re adding value to your affordable health insurance plan. If you have any questions or need more information on anything, please call us 8 a.m.-5 p.m. We are here for you. 1-844-366-2880 (TTY/TDD 1-844-804-6086) SilverSummit Healthplan welcomes all members and is dedicated to giving you quality care. Learn more about Nevada Medicaid today.Plan Preferred Drug List and Prior Authorization List . The SilverSummit Preferred Drug List (PDL) describes the circumstances under which contracted pharmacy providers will be reimbursed for medications dispensed to members covered under the program. All drugs covered under the Nevada Medicaid program are available for SilverSummit members.Welcome to SilverSummit Healthplan, a dedicated member of the Centene family that has been proudly serving Nevada since 2017. We're not just a health insurance provider - …Practitioners who have identified a member who they think would benefit from disease or case management should contact the Care Coordination Department to speak with a member of our Integrated Care Team at 1-844-366-2880. SilverSummit Healthplan's Integrated Care Teams are available to assist members with their individual needs.Do you have silver flatware and don't know what to do with it? Here are the best places to sell silver flatware and get the best price. Home Make Money Are you looking for the bes...We would like to show you a description here but the site won’t allow us.Renewing Medicaid Benefits Form. The form fields are loading, please wait. SilverSummit cannot process your recertification application. If you have any questions about the renewal process, feel free to call us at: 1-844-366-2880 (TTY/TDD 1-844-804-6086). Update your address information on Nevada Medicaid. DWSS services remain available online ...Silver Sneaker classes are a great way to stay fit and healthy. They offer a variety of classes designed to help you improve your overall health and fitness. Whether you’re looking...Wellcare By Allwell from Silver Summit Health 7700 Forsyth Boulevard Clayton, MO 63105. 1-800-977-7522 (TTY: 711) 1-844-796-6811 (TTY: 711)codes can minimize the administrative burden on providers and health plans by greatly decreasing the need for medical record review. Encounters vs Claim An encounter is a claim which is paid at zero dollars as a result of the provider being prepaid - or capitated for the services he/she provided our members. For example; if you are the PMPWelcome to the Start Smart for Your Baby program. We created this program to provide advice and resources for pregnant members and new parents. Whether this is your first child or you already have children, extra support is always helpful. Here you’ll find tips and resources to help you, your new baby, and your family get off to a great start.Upcoming Maintenance. Our websites and portals will be undergoing maintenance and may be unavailable between 8:00am CT and 2:00pm CT on Sunday, 3/17.Wellcare By Allwell from Silver Summit Health 7700 Forsyth Boulevard Clayton, MO 63105. Hello. ... PPO, PFFS, PDP plan with a Medicare contract and is an approved Part D Sponsor. Our D-SNP plans have a contract with the state Medicaid program. Enrollment in our plans depends on contract renewal. Every year, Medicare … For Pregnant and New Moms. $50 - Notification of pregnancy (1 per pregnancy) if completed within 1 st trimester. $25 - Notification of pregnancy if completed within 2 nd trimester. $10 For 6 infant well care visit up to 15 months old. (These visits are recommended at 3-5 days old, before 30 days old, and at 2, 4, 6, 9, 12 and 15 months old) Please use the Grievance, Appeal or Concern Form or call Member Services at 1-844-366-2880 or TTY/TDD 1-844-804-6086. If you have been denied a service that you feel you should receive. please notify us as soon as possible. SilverSummit Healthplan hopes you're always happy with our services and providers of Medicaid in Nevada.We would like to show you a description here but the site won’t allow us. A Bronze plan typically gives you lower monthly premium payments, but potentially higher out-of-pocket costs – if you end up needing a lot of care. And a Gold plan may have higher monthly premiums, but that helps you limit your out-of-pocket costs later. If you’re looking for a balance on your monthly premium payments and your out-of-pocket ... Clinical policies are one set of guidelines used to assist in administering health plan benefits, either by prior authorization or payment rules. They include but are not limited to policies relating to evolving medical technologies … 24/7 Nurse Advice Line. Talk to a registered nurse any time of the day or night with this free service. The 24/7 Nurse Advice Line provides quick, reliable advice for medical situations that aren’t life-threatening. Call the Nurse Advice Line any time at 1-866-263-8134 ( TTY 1-855-868-4945 ). Call the 24/7 Nurse Advice Line if you need: View our 2023 Ambetter Plan Brochure to see the valuable benefits each plan has to offer. 2023 Ambetter Bronze, Silver, and Gold Plan Brochure (PDF) 2023 Ambetter Value Plan Brochure (PDF) Plans may vary by county. Please enter your zip code to see plans available in your area.Choose the Medicaid plan that gets you dollar rewards to spend at Walmart. When SilverSummit members go to the doctor and do other healthy activities, they earn reward dollars they can spend at Walmart on groceries, clothing, electronics, school supplies, appliances, sports equipment, and other things they need. * OUTPATIENT MEDICAID. Complete and Fax to: 1-844-367-7022 Transplant Request Fax to: 1-833-414-1503. Plan Options | Ambetter from SilverSummit Healthplan. For Providers. For Brokers. Shop Our Plans. Plan Options. Bronze or Silver? Find Which Health Plan is Right for You. …Urgent Care. *Applies to qualified individuals. Scan QR code to learn more about all of these free extra benefits & our Dollar Rewards Program or call Member Services at 1-844-366-2880. Mental Health Services. Guaranteed access to Suboxone services. Same Day Access & immediate access to crisis & triage services.This form may be photocopied Required Reconsideration/Appeal Form Use this form as part of SilverSummit Healthplan reconsideration/appeal process to address the decision made during theWe would like to show you a description here but the site won’t allow us.HEDIS (Healthcare Effectiveness Data and Information Set) HEDIS is a set of standardized performance measures developed by the National Committee for Quality Assurance (NCQA) which allows comparison across health plans. Through HEDIS, NCQA holds SilverSummit Healthplan accountable for the timeliness and quality of healthcare services (acute ...SilverSummit provides a broad network of behavioral health providers in Washoe and Clark counties. We also partner with Summit Behavioral Health Services to guarantee access to appointments. Please contact Summit Behavioral Health Services at 702-935-8700 for assistance in getting an appointment. You can also call 1-844-366-2880 and select the ... Visit the ER. If it’s an emergency, call 911. Only visit the emergency room if you have a life-threatening, serious injury, like bleeding or broken bones. Choose other care options if your injury is minor to maximize your benefits and lower your costs. View the article for more tips on care options you can choose. Oct 22, 2021 · MCO contractors now include: • Anthem Blue Cross & Blue Shield. • Health Plan of Nevada. • Molina Healthcare of Nevada (New) • SilverSummit Healthplan. Approximately 75 percent of Nevada’s Medicaid population receive medical benefits through an MCO. With the addition of a fourth MCO for 2022, the new contracts require Nevada Medicaid ... Ambetter Health insurance benefits include: Find out more about health and wellness benefits you gain as an Ambetter Health member. Ambetter is a health insurance provider on the Health Insurance Marketplace. Ambetter from SilverSummit HealthPlan offers affordable plans in Nevada. Learn more.SilverSummit provides a broad network of behavioral health providers in Washoe and Clark counties. We also partner with Summit Behavioral Health Services to guarantee access to appointments. Please contact Summit Behavioral Health Services at 702-935-8700 for assistance in getting an appointment. You can also call 1-844-366-2880 and select the ... Healthy partnerships are our specialty. With Ambetter, you can rely on the services and support that you need to deliver the best quality of patient care. You’re dedicated to your patients, so we’re dedicated to you. When you partner with us, you benefit from years of valuable healthcare industry experience and knowledge. Medicaid eligibility depends on your income. Low income familes, children, pregnant women, disabled, and people above the age of 65 may be eligibile for Medicaid. Enroll in a Medicaid Plan. Coordinated Care is the statewide managed care health plan. Visit Coordinated Care to get you and your family insured today.We would like to show you a description here but the site won’t allow us.Practitioners who have identified a member who they think would benefit from disease or case management should contact the Care Coordination Department to speak with a member of our Integrated Care Team at 1-844-366-2880. SilverSummit Healthplan's Integrated Care Teams are available to assist members with their individual needs.Wellcare By Allwell. Member Services: 1-800-977-7522 (TTY: 711) 1-844-796-6811 (TTY: 711) Not yet a member? 1-844-917-0175 (TTY: 711) Provider Services: 1-800 …TELEHEALTH OPTIONS. SilverSummit now offers telemedicine at no extra cost to you! Get medical help from the comfort of your home or even when you're on the job. Our in-network of providers are available 24/7 to provide advice, diagnosis, or even write you a prescription for non-emergency health issues. You're probably thinking, how does it work ... 24/7 Nurse Advice Line. Talk to a registered nurse any time of the day or night with this free service. The 24/7 Nurse Advice Line provides quick, reliable advice for medical situations that aren’t life-threatening. Call the Nurse Advice Line any time at 1-866-263-8134 ( TTY 1-855-868-4945 ). Call the 24/7 Nurse Advice Line if you need: A Bronze plan typically gives you lower monthly premium payments, but potentially higher out-of-pocket costs – if you end up needing a lot of care. And a Gold plan may have higher monthly premiums, but that helps you limit your out-of-pocket costs later. If you’re looking for a balance on your monthly premium payments and your out-of-pocket ... So, to make working with us easier, we developed the Ambetter Provider Toolkit. It’s designed to provide you with valuable education and materials to simplify your administrative responsibilities—so you can focus on providing care. Ambetter from SilverSummit HealthPlan offers a toolkit of provider resources so you can focus on …1-844-796-6811 (TTY: 711) anytime, day or night. Check out this video for more information about your telehealth and virtual care options. Allwell Telehealth Services. Watch on. Telehealth services with in-network providers work just like face-to-face in office appointments. Your telehealth visits do not require a prior authorization.And if you have a severe medical condition, our Care Managers will work with you, your PCP and managing providers to develop a plan of care that meets your needs and your caregiver’s needs. Call us at 1-866-263-8134 ( TTY 1-855-868-4945 ). If you’re a member of Ambetter, you have access to coverage with Allwell - a Medicare Advantage plan offered from Silver Summit Healthplan. With Allwell, you’ll get the same local service and member experience you’ve come to know, plus more: Affordable healthcare coverage. Benefits you need to take good care of yourself. Welcome to SilverSummit Healthplan. SilverSummit is ready for you. Finally, a health plan that puts you first! It's what we do. We know you are busy, so we make it easy for you. …Medical Oncology, Hematology, Urology, Surgical Oncology, Neurological Oncology, Gynecologic Oncology, and Radiation Oncology will submit their chemotherapy prior authorizations through New Century Health (Effective 11/1/23). Non-participating providers must submit Prior Authorization for all services. For non-participating providers, Join Our ...Practitioners who have identified a member who they think would benefit from disease or case management should contact the Care Coordination Department to speak with a member of our Integrated Care Team at 1-844-366-2880. SilverSummit Healthplan's Integrated Care Teams are available to assist members with their individual needs.The No Surprises Act, as part of the Consolidated Appropriations Act (CAA), has been effective with dates of service on and after January 1, 2022, and provides greater consumer protections to patients by addressing surprise medical bills at the federal level. The No Surprises Act required health plans to implement changes that impact both ...
Our Benefits. Better Coverage. Better Perks. Ambetter Health is on a Mission for Better, and that means better coverage and better perks for you. Beyond great everyday benefits like Virtual 24/7 Care*, members have access to exclusive programs like My Health Pays®** and Ambetter Perks. We’re adding value to your affordable health insurance plan. . Wilfrid laurier campus
Our Health Plans; Enroll in a Plan; Find a Doctor or Pharmacy; Plan Benefit Materials ... Wellcare By Allwell from Silver Summit Health 7700 Forsyth Boulevard Clayton, MO 63105. 1-800-977-7522 (TTY: 711) ... an HMO, PPO, PFFS, PDP plan with a Medicare contract and is an approved Part D Sponsor. Our D-SNP plans have a contract with the state ...Silver Sneakers is a popular fitness program designed specifically for seniors. It offers a wide range of exercise classes and access to fitness equipment, making it a great option...My Health Pays ® rewards program for going to your doctor and doing other healthy activities. Access to safe, effective medications plus savings on over-the-counter items. Boys & Girls Club membership fees covered. Vision coverage includes eye exams and prescription eyewear. Two dental visits every year for brighter smiles.Silver Sneakers is a popular fitness program designed specifically for older adults. With its focus on promoting health and well-being, it has become a favorite among seniors acros...Our Health Plans; Enroll in a Plan; Find a Doctor or Pharmacy; Plan Benefit Materials ... Wellcare By Allwell from Silver Summit Health 7700 Forsyth Boulevard Clayton, MO 63105. 1-800-977-7522 (TTY: 711) ... an HMO, PPO, PFFS, PDP plan with a Medicare contract and is an approved Part D Sponsor. Our D-SNP plans have a contract with the state ...Health insurance is a necessity, but finding a suitable insurance plan that offers the coverage you need, and that is kind to your pocketbook, can be quite a hassle. Let’s take a l...Thank you for your interest in participating with SilverSummit Healthplan. We are excited that you selected our provider network as your network of choice. For Pregnant and New Moms. $50 - Notification of pregnancy (1 per pregnancy) if completed within 1 st trimester. $25 - Notification of pregnancy if completed within 2 nd trimester. $10 For 6 infant well care visit up to 15 months old. (These visits are recommended at 3-5 days old, before 30 days old, and at 2, 4, 6, 9, 12 and 15 months old) Wellcare By Allwell from Silver Summit Health 7700 Forsyth Boulevard Clayton, MO 63105. 1-800-977-7522 (TTY: 711) 1-844-796-6811 (TTY: 711)Please use the Grievance, Appeal or Concern Form or call Member Services at 1-844-366-2880 or TTY/TDD 1-844-804-6086. If you have been denied a service that you feel you should receive. please notify us as soon as possible. SilverSummit Healthplan hopes you're always happy with our services and providers of Medicaid in Nevada.2024 Provider and Billing Manual (PDF) 2023 Provider and Billing Manual (PDF) Quick Reference Guide (PDF) ICD-10 Information. Payspan (PDF) Secure Portal (PDF) Claim Dispute Form (PDF) No Surprises Act Open Negotiation Form (PDF) Non-Formulary And Step Therapy Exception Request Form (PDF)Behavioral Health Forms. For applicable service requests, please include the following clinical documentation: LOCUS/CASII Score and Intensity of Needs Level. Discharge Summaries should be faxed to 1-866-535-6974. Completing an OTR: Tips, Pitfalls & Common Mistakes (PDF) NV Behavioral Health (NBH) Mobile Assessment …We've provided several ways for you to pay your premium. Learn More! Get answers to questions. 1-866-263-8134 ( TTY 1-855-868-4945 ) Emergency Care. Outpatient or Ambulatory Care. Preventive & Wellness Care. Maternity & Newborn Care. Pediatric Care. Mental Health & Substance Abuse Care.Specialties: SilverSummit Healthplan is a managed care organization that will provide healthcare services to Nevada Medicaid and Nevada Check Up members in Clark and Washoe counties. SilverSummit Healthplan has a commitment to improving the health of the community one individual at time. We're here to treat the whole person by breaking …Pharmacy. We are committed to providing appropriate, high-quality, and cost-effective drug therapy to all Ambetter Health members. Use our Preferred Drug List to find more information on the drugs that Ambetter Health covers. 2024 Formulary/Prescription Drug List (PDF) 2023 Formulary/Prescription Drug List (PDF) 90-Day Extended Supply ...Exercising regularly is one of the best things you can do for your health and wellbeing. But with gym memberships costing hundreds of dollars a year, it can be difficult to fit in ...Specialties: SilverSummit Healthplan is a managed care organization that will provide healthcare services to Nevada Medicaid and Nevada Check Up members in Clark and Washoe counties. SilverSummit Healthplan has a commitment to improving the health of the community one individual at time. We're here to treat the whole person by breaking …Careers. SilverSummit Healthplan is a wholly-owned subsidiary of Centene Corporation. We Succeed for Very Talented Reasons – Caring is more than a business opportunity with Centene. It is the reason we exist. It’s the reason we choose to excel. It’s the reason our employees nationwide are valued, respected and rewarded.Behavioral Health appeals: SilverSummit Healthplan - Appeals . 12515-8 Research Blvd, Suite 400 Austin, TX 78759 . Fax 1-866-714-7991 *You may file a grievance at any time. *You must file an appeal within 60 days from the date on the denial letter. PLEASE PRINT Member’s Name: Member’s ID#: Street Address: City. State. Zip. Member Phone Number:.