Fillable Subscriber Change Request Form (Page 3 of 3) in pdf

Subscriber Change Request Form Page 3

Download a blank fillable Subscriber Change Request Form in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Subscriber Change Request Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

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Subscriber Change Request (continued)

Add

Cancel

Child

c Dental

Last name

First name

Sex

c Medical

c Vision

Social Security number:

Date of birth (mm/dd/yyyy) ___________________

HMO/POS Personal Physician name

Dental HMO only dental provider

Current patient?

Doctor’s name: ________________________________

c Yes

Dental provider name:

Provider No. ___________________________________

c No

____________________________________

IPA/MG No. ____________________________________

Dental provider No. _______________

Add

Cancel

Child

c Dental

Last name

First name

Sex

c Medical

c Vision

Social Security number:

Date of birth (mm/dd/yyyy) ___________________

HMO/POS Personal Physician name

Current patient?

Dental HMO only dental provider

Doctor’s name: ________________________________

c Yes

Dental provider name:

Provider No. ___________________________________

c No

____________________________________

IPA/MG No. ____________________________________

Dental provider No. _______________

All information I have provided on this form is accurate and complete. I understand that this form, along with any prior enrollment form, the Evidence of

Coverage/Certificate of Insurance and Health Service Agreement/policy, and any endorsements and attachments thereto, collectively constitutes the

entire agreement for coverage.

Employee signature ________________________________________________________________________________________ Date ___________________

If faxing this form, keep this document for your files.

Blue Shield of California/Blue Shield Life protects the confidentiality and privacy of your personal information. Personal and health information which may

individually identifiable information, such as your name, address, telephone number, Social Security number, and health information. We will not disclose

this information, except as permitted by law.

Please be sure to return this form as the second page contains your signature, which is necessary to process these changes.

* Underwritten by Blue Shield of California Life & Health Insurance Company (Blue Shield Life).

‡ Evidence of Insurability form may be required.

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