Status Change - Vision Plan of America

Status Change Form

INSTRUCTIONS FOR COMPLETING STATUS CHANGE FORM

1. Complete all applicable sections.
2. General enrollee information must be filled out completely.

GENERAL ENROLLEE INFORMATION

Member's Name (as on I.D. card) *:
Address *:
Telephone *:
Member Number (include Group #):
Group/Employer's Name:

CHANGE OF DOCTOR REQUEST

Current Doctor: Facility #
Reason for Change:
New Doctor: Facility #

OTHER CHANGES REQUESTED (Please check one of the following options)

Name Change: Address Change:
New Name:
New Address:
City: Zip:

DEPENDENT(S) TO ADD/DELETE (Please check one of the following options)

Add Delete

1. Name: Birthdate:
2. Name: Birthdate:
3. Name: Birthdate:
4. Name: Birthdate:

DELETE MEMBER(S)

1. Name: Member #
Amount:

2. Name: Member #
Amount:

3. Name: Member #
Amount:

4. Name: Member #
Amount:

* Required Fields