HSS Member Change of Address

Health Service System (HSS) members should use this form to notify HSS of a change in their mailing address. HSS respects your privacy. Your contact information is used only by HSS - this information is never shared.

1. Which type of HSS member is requesting an address change?

Which type of HSS member is requesting an address change? City & County employee

SFUSD employee

SFCCD employee

Retiree

Other (please specify)

2. What is the HSS member's NEW home address?
Street addresses only. You must call Member Services at
(415) 554-1750 if your home address is a post office box.

What is the HSS member's NEW home address? Street addresses only. You must call Member Services at (415) 554-1750 if your home address is a post office box. Name:
Address:
Address 2:
City/Town:
State:
ZIP:

3. What is the HSS member's phone number?
HSS may require phone confirmation of this change of address request.

What is the HSS member's phone number? HSS may require phone confirmation of this change of address request. Phone Number:

4. What is the HSS member's email address?
HSS may require confirmation of this change of address request by email.

What is the HSS member's email address? HSS may require confirmation of this change of address request by email. Email Address: