MEMBER CHANGE FORM - wesley.edu 2026

1. Click ‘Get Form’ to open the MEMBER CHANGE FORM in the editor.
2. 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.
3. 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.
4. 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.
5. Complete your personal information including first name, last name, phone number, and address. Ensure all fields are filled accurately.
6. For covered dependents, repeat the process for each child or spouse/domestic partner by providing their details and selecting appropriate product options.
7. 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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