Hmsa cancellation form 2025

1. Click ‘Get Form’ to open the HMSA cancellation form in our editor.
2. Begin by entering the date at the top of the form. This is essential for processing your request accurately.
3. Fill in your company or group name, followed by the group number. Ensure that this information matches your records to avoid any discrepancies.
4. Provide your address and phone number for contact purposes. This helps HMSA reach you if they need further information.
5. In the section for HMSA number, enter either your current or former number, followed by the employee's name and package number.
6. List any dependents being canceled, including their names, birthdays, and sex. This ensures all relevant parties are accounted for in the cancellation process.
7. In the 'Action Requested' section, clearly state your reason for cancellation or any changes needed. Be specific to facilitate a smooth process.
8. Finally, ensure that an authorized person signs and prints their name at the bottom of the form before submission.

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