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MEMBER CHANGE FORM - wesley.edu 2026
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- Click ‘Get Form’ to open the MEMBER CHANGE FORM in the editor.
- Begin by filling out the 'Employee/Contract Holder Information' section. Enter your effective date, employer/group name, and group number. Select the reason for completion from the provided options.
- For dependent changes, indicate any additions due to a HIPAA life event such as birth or marriage. Be sure to include the date of this event and attach any necessary documentation.
- If applicable, provide details for other changes like a new name or address. Specify if you are canceling dependents due to divorce or death, along with relevant dates.
- Complete your personal information including first name, last name, phone number, and address. Ensure all fields are filled accurately.
- For covered dependents, repeat the process for each child or spouse/domestic partner by providing their details and selecting appropriate product options.
- Finally, review all entries for accuracy before signing at the bottom of the form. Once completed, submit it via fax or mail as instructed.
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2014 | 5 Satisfied (39 Votes) |
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