Change Name

Back To List

Retiree Information

Current Name

First Name

Initial

Last Name

New Name

First Name

Initial

Last Name

Effective Date

Documents

Supporting Document (Driver's License/Medicare Card/Birth Certificate)

Declaration and Signature

By selecting the boxes below, I acknowledge that:

Participation in the New Mexico Retiree Health Care Act is subject to specific eligibility requirements and that benefits offered through the New Mexico Retiree Health Care Authority are subject to legal limitations. Ineligible individuals cannot receive benefits through this program and will benefits or services will not exceed legal limitations. Submitting information on this page is only an application for benefits and does not create any contractual relationship or impose any duties on the part of the New Mexico Retiree Health Care Authority. I must comply with all program requirements, including making timely payments, to enroll and participate. I agree that the New Mexico Retiree Health Care Authority may terminate my participation in this program for noncompliance. I have carefully read and understood all statements on this page and included with this submission, approve all indicated changes, and elect the coverages and benefits selected. I am the actual person applying for benefits whose signature appears below or I am signing on another's behalf under a power of attorney. (If I am signing on another's behalf under a power of attorney, I have attached current authorizing documents or ensured that the New Mexico Retiree Health Care Authority has current authorizing documents on file.)

By typing my name in the space provided below, I hereby declare that all the information I have provided in connection with this application is true and complete to the best of my knowledge.

Type full name in the box below

Today's Date

Discard Changes and Exit Submit Changes and Exit