Get Member Termination/change Form (for Groups Only) - Phs

Filling out the Member Termination/Change Form for groups is a straightforward process that is essential for managing employee health plan memberships effectively. This guide provides detailed instructions to assist you in completing the form accurately and efficiently.

Follow the steps to complete the form successfully.

1. Press the ‘Get Form’ button to obtain the Member Termination/Change Form. This action will open the form in your chosen editor for further modifications.
2. Input today’s date in the specified field. This date is critical as it marks the initiation of the termination or change request.
3. Complete the group information section. Provide the group name and group number in the designated fields to identify the entity managing the health plan.
4. Fill in the employee information section. Include the Employee ID and the full name (first name, middle initial, last name) of the member whose termination or change is being processed.
5. Indicate the type of termination by selecting the appropriate option: Contract, Member, or COBRA. If this form involves an address change, please provide the new address in the indicated space.
6. Answer the question regarding whether the termination of these members will result in zero membership by selecting 'Yes' or 'No'. This detail impacts future billing and membership status.
7. If applicable, add any remarks in the designated section. This can include additional notes regarding the termination or specifics about the dependent only.
8. Fill in the effective date in the format (m/d/yr). This date indicates when the termination or change will officially take effect.
9. Select the coverage term code by marking either 1 for Voluntary Term or 2 for Involuntary Term. This code categorizes the nature of the termination.
10. Once all sections are appropriately filled out, save any changes you have made, and consider downloading or printing the form for your records. Ensure to submit the form as per the instructions provided at the top of the document.

Begin filling out the Member Termination/Change Form online today to ensure smooth management of your group's health plan memberships.