Member change form - Matson Insurance - bcfs 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the Employee/Contract Holder Information section. Enter your effective date, employer/group name, and group number.
3. Indicate the reason for completion by selecting the appropriate option, such as canceling an entire contract or making dependent changes due to a HIPAA life event.
4. For dependent changes, provide details like the date of the event and attach any necessary documentation, such as a HIPAA Certification Form if applicable.
5. Complete the Other Changes section if applicable, including new name or address updates. Ensure you provide dates for any changes made.
6. Fill in your personal information including first name, last name, phone number, address, date of birth, and social security number.
7. If applicable, complete the Covered Dependent Information section for each dependent you wish to add or update.
8. Finally, review all entries for accuracy before signing and dating the form at the bottom. Submit via fax or mail as instructed.

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