Change Address / Phone

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Retiree Information

What would you like to change? Mailing Address Physical Address Phone

Is your address outside of the United States? Yes No

Mailing Address

Country

Region Code

City

State

Zip Code

Physical Address

Country

Region Code

City

State

Zip Code

Contact

Primary Phone

Alternate Phone

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.

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