Change Request Form BlueChoice … · Premiums are drafted from my account: ... For legal reasons,...

Change Request Form BlueChoice ® HealthPlan Individual Health Coverage If you would like to make changes, such as correct a phone number, email address or cancel your entire plan, please ﬁll out this form and send it to us at the address below. Please contact Member Services at 855-816-7636 with any questions you may have. ID Card Number: _____________________________________________________ Phone: ______________________________ Policyholder’s Name: Policyholder’s Address: City: State: ZIP Code: I want to correct: Phone Number Email Address Phone Number: Email Address: I want to add: Social Security Number (SSN) SSN to be added: I want to cancel my plan effective my next due date of: / / . Premiums are drafted from my account: Yes No Note: All cancellations will be effective at the end of the month in which we receive your request. Reason for Cancellation: Add Change Cancel (Include a copy of a canceled check from the account you want us to draft. Allow 30-45 days for the bank draft setup/changes.) Note: For legal reasons, you must present all changes in writing. The policyholder, or parent/guardian if the policyholder is a minor, must sign, not type, the change request. We will not honor requests without a valid signature. How to reply: Mail this form along with any necessary documentation to: BlueChoice HealthPlan, Attn: Billing AX-430, P.O. Box 6000, Columbia, SC 29260 Or, you can email this form to: [email protected]. BlueChoice HealthPlan is an independent licensee of the Blue Cross and Blue Shield Association. First and/or Last Name First and/or Last Name: 100745-09-2017 I want to remove: Name: Date of Birth: SSN: Address Address: Automatic Draft: Bank Name: Bank Routing #: Bank Account #: Account Holder’s Name: Signature: Credit Card Number: Expiration Date: CVV/CVC: Name on Card (if different from subscriber): Billing Address (if different from address on ﬁle):

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Transcript of Change Request Form BlueChoice … · Premiums are drafted from my account: ... For legal reasons,...

Page 1: Change Request Form BlueChoice … · Premiums are drafted from my account: ... For legal reasons, ... BlueChoice HealthPlan is an independent licensee of the Blue Cross and Blue

Change Request FormBlueChoice® HealthPlan Individual Health Coverage

If you would like to make changes, such as correct a phone number, email address or cancel your entire plan, please fill out this form and send it to us at the address below. Please contact Member Services at 855-816-7636 with any questions you may have.

ID Card Number: _____________________________________________________ Phone: ______________________________

Policyholder’s Name:

Policyholder’s Address:

City: State: ZIP Code:

I want to correct: Phone Number Email Address

Phone Number: Email Address:

I want to add: Social Security Number (SSN) SSN to be added:

I want to cancel my plan effective my next due date of: / / .

Premiums are drafted from my account: Yes No

Note: All cancellations will be effective at the end of the month in which we receive your request.

Reason for Cancellation:

Add Change Cancel

(Include a copy of a canceled check from the account you want us to draft. Allow 30-45 days for the bank draft setup/changes.)

Note: For legal reasons, you must present all changes in writing. The policyholder, or parent/guardian if the policyholder is a minor, must sign, not type, the change request. We will not honor requests without a valid signature.

How to reply: Mail this form along with any necessary documentation to:BlueChoice HealthPlan, Attn: Billing AX-430, P.O. Box 6000, Columbia, SC 29260Or, you can email this form to: [email protected].

BlueChoice HealthPlan is an independent licensee of the Blue Cross and Blue Shield Association.

First and/or Last Name

First and/or Last Name:

100745-09-2017

I want to remove: Name: Date of Birth: SSN:

Address

Address:

Automatic Draft:

Bank Name: Bank Routing #:

Bank Account #: Account Holder’s Name:

Signature:

Credit Card Number: Expiration Date: CVV/CVC: