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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.

Question Title

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

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

San Francisco Unified School District (SFUSD) employee

Retiree

City College of San Francisco (SFCCD) employee

Other (please specify)

Question Title

2. 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 (415) 554-1750.

Name:

Address:

Address 2:

City/Town:

State:

ZIP:

Country:

Question Title

3. 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:

Question Title

4. 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:

Question Title

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

email Address: