Get Aca Plan - Individual Member Change Form - Sierra Health And Life 2020-2025

Filling out the ACA Plan - Individual Member Change Form online can be a straightforward process when you have clear guidance. This guide will provide you with step-by-step instructions to ensure you complete the form accurately and efficiently.

Follow the steps to fill out the form with ease.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling in the effective date and date processed fields at the top of the form. This information helps keep track of when the changes are applicable.
3. In the 'Request' section, select one of the options provided: 'Change Coverage (Open Enrollment)', 'Change Coverage (Qualifying Event *Documentation Required)', or 'Add Eligible Dependent(s)'. Make sure to indicate your choice by marking the appropriate checkbox.
4. Fill out the member/insured’s information. This includes your full name, date of birth, member/insured ID number, street address, city, state, zip code, phone number, and email address.
5. If you are changing coverage, please indicate the plan option you are requesting by selecting from the Health Plan of Nevada or Sierra Health and Life options. Mark the corresponding checkboxes for the plans you wish to select.
6. If applicable, respond to the optional product offerings section regarding vision and dental plans by selecting 'Yes' or 'No'.
7. If you are adding eligible dependents, complete the appropriate sections for each dependent. For a spouse or domestic partner, provide their full name, date of birth, and date of marriage/domestic partnership. Ensure you also list the primary care physician if applicable.
8. For children being added, fill in their full name, email, date acquired, relationship, daytime phone number, sex, and if applicable, information regarding their OB/GYN and primary care physician.
9. Once all relevant fields are completed, review your information for accuracy. If necessary, make any adjustments.
10. Finally, save your changes, and depending on your needs, download, print, or share the form as required.

Take action now by filling out the ACA Plan - Individual Member Change Form online!