Request a New ID Card

Your ID Card should be shown each time you visit a provider’s office or facility.  Upon enrollment, you will be issued two ID cards.  If you wish to receive additional cards for your dependents or need a replacement card to be issued for you and/or any of your covered dependents, please submit the form below for each card you need replaced.



Member Number (on ID card)
Group Number
*Member First Name  
*Member Last Name  
Middle Initial
*Address  
*City  
*State
*Zip  
*Phone Number  
*Member Email Address    
*Reason for Requesting
(lost, never received, etc.)
 
*Mail a new ID card to
First Name, Last Name, Member Number