Member Update Form

Do you need to make changes to your personal information?

Elderplan can help while ensuring your privacy.

Make changes or written requests in four easy steps:

• Download this document to update the following information:
  Member Information Update Form English | Español
  (requires Adobe Reader, free from Adobe Systems):
  • Change of address
  • Change Primary Care Physician (PCP)
• Get a new Elderplan member card (Reminder: While you DO NOT use your Medicare card for medical services, be sure to keep it in a safe place)
• Print the form on your computer’s printer
• Fill in the form completely, including your Elderplan Member ID number
• Mail or fax your form to the following address:
  Elderplan Member Service
  6323 Seventh Avenue
  Brooklyn, NY 11220
  Fax: 718-630-2624

If you have any questions about changes you make to your personal information or any written requests, please don’t hesitate to contact Elderplan’s Member Services Department.

Elderplan Member Service
6323 Seventh Avenue
Brooklyn, NY 11220
Fax: 718-630-2624

If you have any questions about changes you make to your personal information or any written requests, please don’t hesitate to contact Elderplan’s Member Services Department.