Member Change Form

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Member Change Form
Submit Completed Form to:
Common Ground Healthcare Cooperative
PO Box 1630
Brookfield, WI 53008-1630
MEMBER ID # _______________________________________________________
GROUP NUMBER _______________________________________________________
I. Applicant Information
FIRST NAME
M.I.
LAST NAME
DATE OF BIRTH
HOME ADDRESS – STREET
CITY
STATE
ZIP CODE
r
PRIMARY PHONE (include area code)
SECONDARY PHONE (include area code)
EMAIL ADDRESS
II. Reason for Application
A. UPDATE PERSONAL DATA - Choose all that apply.
Name Change - Indicate former name: ______________________________________________
Address Change - Indicate updated address in Section I.
Telephone Number Change - Indicate updated number in Section I.
Date of Birth Correction - Change date to (mm/dd/yyyy) _____________________________ for (Name) ______________________________________________
Social Security Number Correction - Change SSN to _____________________________ for (Name) ________________________________________________
B. ADD DEPENDENT(S) - Update Section III below. Date of Event: __________________________________________
Birth
Marriage
Loss of Coverage (Please attach proof of loss.)
Adoption
Domestic Partner
Other: ___________________________________________________
(if provided by employer)
C. REMOVE DEPENDENT(S) - Update Section III below. Date of Event: _______________________________________
Death
Dependent no longer eligible
Grandchild’s parent turns 18
Divorce
Domestic Partnership Terminated
Other: _________________________________
(if provided by employer)
D. CHANGE BENEFIT PLAN DESIGN - Indicate current health plan, choose one and indicate the effective date. Update Section III below.
Current Benefit Plan Design: ____________________________________________
New Benefit Plan Design: ______________________________________________
Effective Date: ____________________________
E. CANCEL COVERAGE
Cancel my Current Coverage
Reason: ______________________________________________________________________________
Effective Date of Cancellation: _____________________________________________________________
III. Dependent Information
- List all dpendents to be added or deleted.
DEPENDENTS (Indicate last name ONLY if different than applicant.):
NAME (FIRST, MI, LAST)
SOCIAL SECURITY NUMBER
DISABILITY (Y/N)
DATE OF BIRTH (MM/DD/YYYY)
RELATIONSHIP
SEX (M/F)
TOBACCO USE* (Y/N)
*Not applicable if an employer group.
PO Box 1630 | Brookfield, WI 53008-1630
877.514.2442
262-754-9690
TOLL-FREE
FAX
WEB

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