SFHSS Member Change of Address Form

San Francisco Health Service System (SFHSS) members should use this form to notify SFHSS of a change in their mailing address. Your request will be processed by a Member Services Benefits Analyst. SFHSS respects your privacy. Your contact information is used only by SFHSS - this information is never shared.

Once you update your address, please call SFHSS immediately at (628) 652-4700 to confirm your new address is still within your current medical plan coverage area.

Question Title

1. Which type of SFHSS Member is requesting an address change?

San Francisco Unified School District (SFUSD) employee

City College of San Francisco (SFCCD) employee

Retiree

City and County of San Francisco employee (Superior Court of San Francisco employees should select this)

Other (please specify)

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2. Please enter your Employee ID (DSW) Number

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3. What is the SFHSS Member's NEW HOME ADDRESS?
Street addresses only. Enter P.O. Box addresses under Mailing Address below.
If you have any questions about changing your Home Address, please call
SFHSS at (628) 652-4700.

Name: *

Address: *

Address 2:

City/Town: *

State: *

ZIP: *

Country:

Question Title

4. What is the SFHSS Member's NEW MAILING ADDRESS, if any?
Mailing addresses are optional. Do not enter anything if your mailing address is the same as your Home Address.

Name:

Address:

Address 2:

City/Town:

State:

ZIP:

Country:

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5. What is the SFHSS Member's Preferred Phone Number?
SFHSS may require phone confirmation of this change of address request.

Type of Phone:

Phone Number: *

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6. What is the SFHSS Member's Preferred email Address?
SFHSS may require confirmation of this change of address request by email.

email Address:

Question Title

1. Which type of SFHSS Member is requesting an address change?

Question Title

2. Please enter your Employee ID (DSW) Number

Question Title

3. What is the SFHSS Member's NEW HOME ADDRESS?Street addresses only. Enter P.O. Box addresses under Mailing Address below. If you have any questions about changing your Home Address, please call SFHSS at (628) 652-4700.

Question Title

4. What is the SFHSS Member's NEW MAILING ADDRESS, if any? Mailing addresses are optional. Do not enter anything if your mailing address is the same as your Home Address.

Question Title

5. What is the SFHSS Member's Preferred Phone Number? SFHSS may require phone confirmation of this change of address request.

Question Title

6. What is the SFHSS Member's Preferred email Address?SFHSS may require confirmation of this change of address request by email.

3. What is the SFHSS Member's NEW HOME ADDRESS?
Street addresses only. Enter P.O. Box addresses under Mailing Address below.
If you have any questions about changing your Home Address, please call
SFHSS at (628) 652-4700.

4. What is the SFHSS Member's NEW MAILING ADDRESS, if any?
Mailing addresses are optional. Do not enter anything if your mailing address is the same as your Home Address.

5. What is the SFHSS Member's Preferred Phone Number?
SFHSS may require phone confirmation of this change of address request.

6. What is the SFHSS Member's Preferred email Address?
SFHSS may require confirmation of this change of address request by email.