Terminate Blue Shield Insurance Form

Member submitted claim forms.

Terminate blue shield insurance form. It is important that the termination code and effective date be listed. President consumer directed benefit solutions memphis tennessee if you are covered under an individual health insurance policy you should be able to either contact your insurance broker to request their assistance in terminating your policy or contact blue cross blue shield s member services department to request a termination form. Fill out an eligibility change transmittal form. Change of status form employers can give this form to employees who need to enroll in a health insurance plan choose primary care physician or update their personal information.

To cancel an employee s coverage for either a blue shield of california plan or a blue shield of california life health insurance company plan follow these steps. Blue cross and blue shield association. Box 2181 little rock ar 72203 2181. Blue cross blue shield global core international claim form file claims from providers outside the u s.

Cancel a health insurance benefit plan. All fields marked with a red asterisk are required. 410 505 2901 or toll free 800 305 1351. This form is not intended to be used for termination of a provider agreement contract and you will need to contact your local network representative directly for these requests.

Blue cross and blue shield association a highmark affiliate how to complete your report of termination activity form completing the report of termination activity form terminating members an employee whose coverage is to be terminated must be listed on this form. Suite 300 lombard il 60148. Beneficiary change form pdf 452kb life insurance additional contact designation form pdf 1 06mb claim forms. Enterprise exchange services membership po box 2181 little rock ar 72203 2181 601 s.

Arkansas blue cross blue shield attn. The information you give us is also used to update our provider tools. Members on a plan with prefix yep should contact the federal marketplace ffm at 800 318 2596 to cancel coverage. Subscriber s statement of claim form pdf 418kb subscribers should use this form only when the provider of service does not submit a claim directly to blue shield subscriber claim form for services received outside california.

You can send this form to us via. Blue cross and blue shield of texas is the trade name of dearborn life insurance company an independent licensee of the blue cross and blue shield association. Individual insurance coverage termination form maryland washington d c and northern virginia not for coverage obtained through the federal exchange mail administrator. Insurance products issued by dearborn life insurance company 701 e.

List the employee s name blue shield id number or social security number and employment termination date.