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Click ‘Get Form’ to open it in the editor.
Begin by filling out the Participant Information section. Enter your name, Social Security number, date of birth, mailing address, and contact numbers.
In the Transferring Provider Information section, specify the name of your current provider and include any relevant account or policy numbers.
Next, provide details in the Receiving Provider Information section. Ensure that this provider is approved under your employer’s plan and include their name and account/policy numbers.
Complete the Participant Acknowledgement section by signing and dating the form to confirm your request for an exchange.
Finally, review all entered information for accuracy before submitting the form to AFPlanServ™ at the provided address.
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If you have questions or want to check the status of the form, please contact National Benefit Services at 1-800-274-0503 ext. 5. After this form has been
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