Form Lg02 - Status Change Form
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1Form LG02
FOR LGHIB USE ONLY
Revised 10/15
: ___________
Date
LOCAL GOVERNMENT HEALTH INSURANCE PROGRAM
: __________
2016 STATUS CHANGE FORM
Initials
SUBSCRIBER INFORMATION (Please print or type.)
Name (First, Middle Initial, Last)
Date of Birth
Social Security Number
Contract Number
Home Telephone Number
Work Telephone Number
.
CHANGE:
MAILING ADDRESS To: __________________________________________________________________________________________
Street Address or Post Office Box
_________________________________________________________________________________________
City
State
Zip
SUBSCRIBER’S NAME From: _____________________________________ To: ___________________________________________
DEPENDENT’S NAME From: _____________________________________ To: ____________________________________________
SUBSCRIBER’S DATE OF BIRTH From: ____________________________To: ___________________________________________
DEPENDENT’S DATE OF BIRTH From: ____________________________ To: ____________________________________________
TELEPHONE NUMBER To: __________________________________________________________________________________________
E-MAIL ADDRESS To: ___________________________________________________________________________________________
CHANGE RATE:
Retired Subscriber (Not Medicare Participant)
CHANGE RATE:
Retired Subscriber (Medicare Participant)
Dependent not Medicare
Dependent Medicare
Dependent not Medicare
Dependent Medicare
Note: If in your rate above you selected:
Retired Subscriber (Medicare Participant) or
Dependent Medicare,
you must provide a copy of your Red, White, and Blue Medicare Card.
TO BE COMPLETED BY EMPLOYER
AFFIRMATION AND RELEASE
I hereby affirm that I have completely read and fully understand the terms and
Effective Date of Change: ______________________________
conditions of this form. I attest that all the representations made by me on this form
are true and correct. I understand that any misrepresentation may result in the
forfeiture of insurance coverage and that I will be personally liable for all claims
_________________________________________________
related to such misrepresentation. I further understand that there is mandatory
Local Government Unit Name
utilization review and I do hereby give permission to release any information
necessary to evaluate, administer, and process claims for benefits to any person,
_________________________________________________
entity, or representative acting on the LGHIB’s behalf.
Account Number
_________________________________________________
__________________________________________________________________
Signature of Insurance Clerk
Date
Employee Signature
Date
LOCAL GOVERNMENT HEALTH INSURANCE BOARD
POST OFFICE BOX 304900
MONTGOMERY, ALABAMA 36130-4900
334-263-8326 / 1-866-836-9137 / FAX: 334.517-9778
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