Employee Termination Report Form printable pdf download

Employee Termination Report Form

HealthAmerica

Attn: Eligibility Department

PO Box 67103

Harrisburg, PA 17106-7103

Fax: 1-800-788-5447

EMPLOYEE TERMINATION REPORT

Use this form for employee terminations only. For all other enrollments or enrollment changes (e.g. enrolling a new

employee, adding a dependent), please use the HealthAmerica

Enrollment/Change

Form. Terminations submitted on this

report must be received by the 1

of the month or they may not be reflected until your next invoice. Employers must

complete all sections of this form to cancel their employees from coverage. Forms missing required termination

information may delay processing. To expedite processing, please fax to the Eligibility Department at 1-800-788-5447. If

you have questions or to confirm processing, please contact the CARETeam at 1-800-404-9886.

Date:____________________

Group Name:

Phone Number:

Group Number:

Email Address

Contact Name:

Contact Title:

Contact Signature:

*Reasons for Termination*

1. Employment terminated

4. Non-payment of premium

2. Moved out of the area

5. Other coverage

3. Loss of eligibility

6. Deceased

Term

Subscriber

Social Security

Employee’s Name

Last Day of

Reason

ID Number

Number

Last, First, Middle Initial

Employment

Coverage

Code

C o v e n t r y D a t a C la s s if ic a t io n : P u b lic D o m a in

R e v . 0 5 0 9 1 1

Employee Termination Report Form

Related Articles

Related forms

Related Categories