Florida Blue Cancellation Of Insurance Form

I have obtained a policy with another company and am sending you this written notice to request cancellation of my current insurance policy.

Florida blue cancellation of insurance form. Direct membership billing po box 45074 jacksonville fl 32232 5074. Underwritten health change application for direct pay individual under age 65 members hmo for plans with coverage that was already in effect before january 2014. D b a florida blue hmo contract that is selected on this form. Attach a voided check from your checking account.

November 1 2018 if you qualify for a premium tax credit you can enroll in a florida blue plan starting november 1 2018. Your full name street address. These companies are independent licensees of the blue cross. Hmo coverage is offered by health options inc dba florida blue hmo.

Dental life and disability are offered by florida combined life insurance company inc dba florida combined life. This form is used to inform florida blue if you currently have or recently had insurance coverage which your florida blue policy will replace. October 1 2018 you can enroll in a plan directly through florida blue. Life and disability are offered by florida combined life insurance company inc dba florida combined life an affiliate of blue cross and blue shield of florida inc.

Florida blue care management referral form pdf 835 health care electronic remittance advice request form pdf. Hmo coverage is offered by health options inc dba florida blue hmo an hmo affiliate of blue cross and blue shield of florida inc. I understand and agree that the changes will not be effective until this application is accepted by florida blue and or florida blue hmo. Request for cancellation of insurance policy.

Hmo coverage is offered by health options inc dba florida blue hmo an hmo affiliate of blue cross and blue shield of florida inc. Dental life and disability are offered by florida combined life insurance company inc dba florida combined life an affiliate of blue cross and blue shield of florida inc. You can buy a florida blue health plan for 2019 coverage on these dates. Dental life and disability are offered by florida combined life insurance company inc dba florida combined life an affiliate of blue cross and blue shield of florida inc.

Or if using a savings account please attach a voided deposit slip. These companies are independent licensees of the blue cross and blue shield association. I authorize my employer to deduct from my earnings my premium contribution if any including any additional amounts required. Florida blue and florida blue hmo do not discriminate on the basis of race color national origin disability age sex gender identity sexual orientation or health status in the administration of their plans including enrollment and benefit determinations.