MEMBER STATUS CHANGE REQUEST FORM
Use only for presently insured Capital Health Plan Members
Note: Changes must be made in accordance with your contract
Please complete and return this form with any change(s) by: Mail: Capital Health Plan; Attn: Enrollment; PO Box 15349; Tallahassee
FL 32317 Fax: 850.523.7369 OR Email: Enrollment@chp.org
1. Name of Group Employer:
2. Group Administrator Email:
3. Printed Name of Authorized Group Administrator:
4. Phone #:
5. Group #:
Subscriber Information
6. Subscriber’s Name (Last, First, MI):
7. CHP ID #:
8. Check type of change:
Add Dependent(s) Address Change Cancel All Coverage Cancel Dependent(s) Change to Retiree Name Change
Other___________________________________________
Effective Date of Change:
9. Check reason for change: (
∗
Attach the Supporting documentation)
Adoption
∗
Birth Death Divorce
∗
Marriage
∗
Leave of Absence/Layoff Loss of Other Coverage
∗
Moved from Service Area
Open Enrollment Other Insurance Over-age Dependent Retirement Termination of Employment Name Change
∗
Other_________________________________________
Actual Date of Event:
Additions/Deletions of Eligible Family Members (Attach a Separate Sheet, if necessary)
First Name, M
11.
Relation-
ship
12.
Sex/Date
of Birth
13.
SSN
14.
Disabled
15. Primary Care
Physician
16.
Current
Patient
Add
Delete
M F
Yes
No
Yes
No
Add
Delete
M F
Yes
No
Yes
No
Add
Delete
M F
Yes
No
Yes
No
Add
Delete
M F
Yes
No
Yes
No
Add
Delete
M F
Yes
No
Yes
No
Changes: Name and or Address
New
Address
17. Member Permanent Residence Street Address:
18. Mailing Address:
19. Telephone Number:
Name
Change *
20. From: To:
Dependent
Alternate Address
21. Dependent Name:
22. Address:
23. Dependent Name:
24. Address:
Dependent
Alternate Address
25. Dependent Name:
26. Address:
27. Dependent Name:
28. Address:
29. Do you, your spouse, or dependents have other health care coverage? Yes No (If yes, complete the appropriate section(s) on the reverse side of this form)
Acceptance of any Coverage/Membership:
I have read and understand the Change Authorization on the reverse side of this form and the Fraud Warning below:
_________________________________________________________ _________________________________________________________
Signature of Subscriber/Covered Employee Date Signature of Authorized Group Administrator Date
Fraud Warning:
Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an
application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
2020.044.MSCF
2020. 044.MSCF
If more space is needed, attach a separate sheet with additional information.
Other Health Plan Insurance
Medicare
Insured Member’s Name: Date of Birth:
Beneficiary Name:
Beneficiary Name:
Employment Status: Name of Employer:
Active __________________________________________
Retired
Type of coverage: Single Family
Entitlement Reason:
Age 65 or older
End Stage Renal Disease
Other Disability
Entitlement Reason:
Age 65 or older
End Stage Renal Disease
Other Disability
Policy #:
Medicare MBI Number:
Medicare MBI Number:
Name of Insurance Company: Phone:
Part A Effective Date:
Part A Effective Date:
Does the above insurance cover all family members, including yourself?
Yes
No If no, please list the dependents not covered on a separate sheet
.
Part B Effective Date:
Part B Effective Date:
Change Authorization
I hereby authorize the changes to my Capital Health Plan (CHP) contract. I understand and agree that the changes will not be
effective until this application is accepted by CHP. I authorize any physician, medical practitioner, hospital, clinic, or other
medical or medically related facility, insurance company or other organization, institution, or person that has records or
knowledge of me or my eligible family members to give that information to CHP (or other affiliated carrier). This release
specifically includes, but is not limited to, authorization to release any and all medical records and information associated with
reference to certain conditions. I authorize CHP to exchange benefit information with any insurance company, organization, or
individual to determine the applicability of the coordination of benefits provision for myself and my eligible family members for
treatment, payment, and/or health care operations purposes. I represent that my statements on this application are true,
compete, and I understand, and agree that any misstatements may result in denial of benefits and/or termination of coverage.