Member Forms

Download and complete these forms for various Medicaid member services. Contact Med-QUEST if you need assistance.

Application & Enrollment Forms

• Medicaid Application (DHS 1100)
• Change of Information Form
• Address Update Form
• Health Plan Selection Form
• Health Plan Change Request

Appeals & Grievances

• Member Grievance Form
• Appeal Request Form
• Fair Hearing Request Form
• Expedited Appeal Request

Other Member Forms

• Medical Transportation Request
• Release of Information Authorization
• Primary Care Provider Change Form
• Out-of-State Care Request
• Third Party Liability Form