Instructions for completing Status Change Form 1. Complete all applicable sections. 2. General enrollee information must be filled out completely.General Enrollee InformationMember's Name (as on I.D. card)* Address* Telephone* Member Number (include Group #) Group/Employer's Name Change of Doctor RequestCurrent Doctor Facility # Reason for Change New Doctor Facility # Other Changes RequestedPlease check one of the following options Name Change Address Change New Name New Address City Zip Dependent(s) to add/deletePlease choose 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
