Get Change of Address Form

CHANGE OF ADDRESS FORM Return this Form to MPI P. O. Box 1999 Studio City CA 91614-0999 Toll Free 855 275-4674 Fax 818 766-1229 Email service mpiphp.org PARTICIPANT ADDRESS CHANGE INFORMATION Please Select One Participant Retiree/Survivor Spouse Child Address Type Physical Mailing Third Party Type Name MPID / SSN New Address Date of Birth Effective Date s City State Email Phone Zip Fax If you would like personal health information to be sent to someone other than yourself you need to complete an Authorization for Release of Health Information. If you are requesting the release of your Health and/or Pension information to a person with a Power of Attorney Conservator or any third party you must have the required legal documentation on file with MPI. Additional information and required forms for releasing your Health and Pension information may be found at www. Mpiphp.org. DEPENDENT ADDRESS CHANGE INFORMATION Same as Participant s Above Relationship PARTICIPANT S CONSENT I understand that the information I provided above will be used to update my records for both the Motion Picture Industry MPI Pension and Health Plans. I must provide separate notification to all Employers Local Unions and Credit Unions. I further understand that I must submit this form to MPI s address above each time this information changes to ensure I receive Plan information. My signature is required to validate the information on this form. Date. Additional information and required forms for releasing your Health and Pension information may be found at www. mpiphp*org. DEPENDENT ADDRESS CHANGE INFORMATION Same as Participant s Above Relationship PARTICIPANT S CONSENT I understand that the information I provided above will be used to update my records for both the Motion Picture Industry MPI Pension and Health Plans. I must provide separate notification to all Employers Local Unions and Credit Unions. I further understand that I must submit this form to MPI s address above each time this information changes to ensure I receive Plan information* My signature is required to validate the information on this form* Date. Additional information and required forms for releasing your Health and Pension information may be found at www. mpiphp*org. DEPENDENT ADDRESS CHANGE INFORMATION Same as Participant s Above Relationship PARTICIPANT S CONSENT I understand that the information I provided above will be used to update my records for both the Motion Picture Industry MPI Pension and Health Plans. .