Request to Add, Terminate or Change Other Insurance 2026

1. Click ‘Get Form’ to open it in the editor.
2. In SECTION 1, select whether you want to 'Add', 'Terminate', or 'Change' insurance by checking the appropriate box.
3. Proceed to SECTION 2 and fill in your information as the requester, including your name, county/local health department, date, phone number, fax number, and case number if available.
4. In SECTION 3, list the beneficiaries or clients whose insurance status you wish to modify. For each individual, provide their name, date of birth, and miHealth ID.
5. SECTION 4 requires policyholder information. Fill in the policyholder's name, employer details, date of birth, social security number, type of coverage selected from the options provided, and insurance company names along with group/policy numbers.
6. In SECTION 5, indicate the reason for change by selecting from options like divorce or employment termination. Provide relevant dates and any additional explanations as needed.
7. Attach any necessary documentation that supports your request and ensure all mandatory fields marked with an asterisk (*) are completed before submission.

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