23720 PH005 Change form

Change Form
PriorityHealth
Health• • PO
POBox
Box205
205• •Grand
GrandRapids,
Rapids,MIMI49501-0205
49502-0472
Priority
(Member changes must be received by Priority Health within 31 days of the event.)
Fax to 616 942-5242
SECTION 1 - EMPLOYEE INFORMATION
Employee’s Last Name
First Name
Middle Initial
Social Security Number
SECTION 2 - CHANGES (Please complete only those changes which apply.)
ADDRESS/PHONE CHANGE
State
Street Address
Zip Code
Home Phone
(
)
New Last Name
NAME CHANGE
City
Last Name
2
First Name
Bir th Date
Sex
Female
Male
Has this dependent ever seen this provider?
No
Yes
Last Name
Relation to Employee
Bir th Date
Relation to Employee
Sex
Male
Female
Has this dependent ever seen this provider?
No
Yes
4
Bir th Date
Sex
Female
Male
Has this dependent ever seen this provider?
No
Yes
Sex
Female
Male
Has this dependent ever seen this provider?
No
Yes
Reason for Change
Delete
Add
Social Security Number
Middle Initial
Primary Care Provider (REQUIRED for HMO & POS)
First Name
Middle Initial
Social Security Number
Primary Care Provider (REQUIRED for HMO & POS)
PCP Address/ID Code
First Name
Middle Initial
Social Security Number
Primary Care Provider (REQUIRED for HMO & POS)
Relation to Employee
PCP Address/ID Code
Last Name
Birth Date
Date Change Occurred
PCP Address/ID Code
Last Name
3
-
Former Last Name
DEPENDENT CHANGE (If you have more than 4 dependent changes please complete an additional change form).
1
Work Phone
(
)
-
First Name
Middle Initial
Social Security Number
Primar y Care Provider (REQUIRED for HMO & POS)
Relation to Employee
PCP Address/ID Code
SECTION 3 - AUTHORIZATION
I authorize Priority Health to make the changes indicated above for me and my dependents. I understand that Priority Health may request pertinent
sworn statements if needed and that I must sign and date this form before it will be processed.
Priority Health requires proper handling of personal health information for our members. Details of our confidentiality policies and procedures are
available upon request.
X __________________________________________________________________________________________________
Employee Signature
Date
Employer Name
Group Number
Sub Group Number
Employer/Representative Signature
Date
Plan Change
(If checked, please also check one of the following)
HMO
Plan Option (if applicable)
High
Mid
Low
REASONS FOR ADDITIONS
Birth
Adoption
Divorce
Death
Lost Eligibility
Marriage
REASONS FOR DELETIONS
Marriage of Dependent
Divorce
Death
Lost Eligibility
POS
PPO
HBC
Death
For Priority
Health Use Only
Lay Off
COBRA Terminated
Date Received
Leave of Absence
Dissatisfied
HRA
Loss of other coverage (Proof Required)
Other
HSA
Other
_________
Date Occurred
Changed Health Plans
Other
Effective Date
Date Coverage Ended
_________________________
REASON FOR TERMINATION OF ENTIRE CONTRACT
Terminated Employment
Class
Date Coverage Ended
Moved out of area
______________________________
Processor
Code
Date Processed
In accordance with the Genetic Information Nondiscrimination Act (GINA) of 2008, Priority Health requests that
you not include any genetic information on this form. Genetic information includes any genetic testing results of
either yourself or a family member, your family health history or any requests for or receipt of genetic services.
The term “Priority Health” refers to three corporations: “Priority Health,” “Priority Health Managed Benefits, Inc.”
and “Priority Health Insurance Company.”Priority Health is a registered trademark and is used by permission of the owner.
PH005 5543b 03/10