SFHSS Member Change of Address Form

San Francisco Health Service System (SFHSS) Retiree members can use this form or eBenefits to submit your change of address.

SFHSS does not share your contact information. Please visit our privacy page for more information.

If you are not a Retiree, please do not use this Form. Your change of address will not be processed. Please refer to your respective employer instructions to change your address here.

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.

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

Retiree

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2. Please enter the Effective Date.

If you are not moving outside of your current plan's service area, enter your move date. This date must be today's date or later.

If you are moving outside of your current plan's service area, please enter an effective date that is at least 30 days from today to allow enough time to process your change.

If you move your primary residence to a location outside your health plan’s service area, you cannot obtain services through that plan.  Do not risk termination of coverage. You must enroll in a different SFHSS plan that offers service based on your new address.

Submit a completed SFHSS Application Form to elect a new health plan within 30 days of your move. Coverage under the new plan will be effective the first day of the coverage period following the date SFHSS receives your enrollment application and any required documentation.

For Retiree Non-Medicare Application Form, click here.
For Retiree with Medicare Application Form, click here.

Contact SFHSS to determine your new service area coverage at (628) 652-4700.

Please do not enter a date earlier than today.

Date

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3. Please enter your Employee ID (DSW) Number

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4. Do you currently have Kaiser Permanente Senior Advantage as your medical insurance? If you answer yes, please call SFHSS at (628) 652-4700 to determine if you have moved outside of a Kaiser Permanente Senior Advantage service area. You may need to complete a Kaiser Disenrollment Form.

Yes

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5. What is the SFHSS Member's PREVIOUS HOME ADDRESS?

Please enter your previous Street address and Zip Code so that we may verify your records when updating your new address.

Street Address: *

Address 2:

ZIP: *

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6. 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:

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7. 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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8. 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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9. What is the SFHSS Member's Preferred email Address?
SFHSS may require confirmation of this change of address request by email.

email Address:

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

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3. Please enter your Employee ID (DSW) Number

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4. Do you currently have Kaiser Permanente Senior Advantage as your medical insurance? If you answer yes, please call SFHSS at (628) 652-4700 to determine if you have moved outside of a Kaiser Permanente Senior Advantage service area. You may need to complete a Kaiser Disenrollment Form.

Question Title

5. What is the SFHSS Member's PREVIOUS HOME ADDRESS?Please enter your previous Street address and Zip Code so that we may verify your records when updating your new address.

Question Title

6. 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.

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7. 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.

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

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

5. What is the SFHSS Member's PREVIOUS HOME ADDRESS?

Please enter your previous Street address and Zip Code so that we may verify your records when updating your new address.

6. 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.

7. 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.

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

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