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Membership Status/Information Change Form
P.O. Box 14326Reading, PA 19612
www.SeeChangeHealth.comMain: 866-340-7182Fax: 610-374-6986
1. Change of Dependent (Please return the completed form to the above address)
Addition and Deletion of dependent: (If additional space is needed, please use a photocopy of this page)
2. Termination of Employee
Please provide the following termination details (Please use a photocopy of this page, if additionalspace is needed)
Reason forChange
Add, Deleteor Change Full Name Relationship
Sex(M or F)
Date of Birth(MM/DD/YYYY)
New Born
Adoption
Marriage
Add
Delete
Change
Other
DomesticPartnership
New Born
Adoption
Marriage
Add
Delete
Change
Other
DomesticPartnership
New Born
Adoption
Marriage
Add
Delete
Change
Other
DomesticPartnership
Member ID(SeeChange)
Full Name Sex(M/F)
Date of Birth(MM/DD/YYYY)
Employer Name: _____________________________________ Employer ID Number: _________________________
Employee Name:_____________________________________ Employee ID Number:_________________________
Effective Date of Change: ___________________
3. Coverage Change
4. Employee Information and Updates
Please provide the following details for change of coverage type (Please use a photocopy of this page, ifadditional space is needed)
Member ID(SeeChange) Full Name
Name of Employer Office/Owner Approval Signature
Type ofCoverage Reason
Sex(M or F)
Dateof Birth
Employee
Employee + children
Employee + spouse
Family
Employee
Employee + children
Employee + spouse
Family
Employee
Employee + children
Address Change
Address Change Name Change Other
Employee + spouse
Family
I hereby apply for amendment of my application to SeeChange Health Inusrance Company, Inc. It is mutually agreed that these changes shall not become effective unless this application is accepted. As stated in my certificate of coverage, the effective date of such change shall coincide with the 1st of the month, following the date of the benefit or classification change (newborns are effective immediately). Changes due to termination will be effective the last day of the month. This application for change will become part of my original application and will be subject to terms and agreement in effect. Group changes due to employment termination will be effective the 1st of each calendar year.
Current Information.
Employee Name Member ID
Current Name
Member ID
Name Change
If Other, Please specify
Member ID
Apt. NoHome Address
City State Zip
New Name
5. Authorizations and Declarations
As I am changing my status, and by signing this document I declare under the penalty of perjury under the laws of the state of California that the following statements are true and correct regarding the above enrolling dependents, as applicable:
I am either actively, permanently working for the employer and considered eligible by my employer, because I work, either 30+ hours per week, or I am an eligible COBRA/Cal-COBRA participant.
• I am not a temporary, seasonal, per diem or a 1099 employee or insured by or eligible to be insured by the employer’s union policy.
• My spouse and I are legally married as recognized by the state of California.
• My partner and I are legally recognized as a domestic partnership by the state of California.
• My children's dates of birth are accurate.
• My children are: unmarried or not involved in a domestic partnership, and are financially dependent upon me per the IRS guidelines.
• My children are born to me or my spouse/domestic partner, or legally adopted and/or a non temporary legal ward of me or my spouse/domestic partner.
• My name change or address change is not being done for improper purposes.
I understand that I may be asked for legal proof of the above at any time. I understand that false statements and/or failure to provide the information upon request will cause the termination of all benefits 15 days following the date of the notice of termination and I will be held responsible for all services and charges incurred through providers thereafter.
I understand that any persons, businesses, or health plans that suffers a loss because of false declarations contained in this statement may have cause to bring civil action against me to recover their losses.
The representations made are the basis upon which coverage may be issued. If any material fact was omitted or misrepresented, the coverage may be cancelled or the employer’s contract rescinded.
I have READ, UNDERSTAND and ATTEST that myself, my spouse, my partner and/or my dependents have met all of the eligibility requirements.
CA-S-MSICF-20120210 SeeChange Health Insurance Company, Inc.
Employee’s Signature Date
