Get Membership Termination Form - Upmc Health Plan

This guide provides a comprehensive overview of how to accurately complete the MEMBERSHIP TERMINATION FORM for UPMC Health Plan online. Whether you are terminating your membership or managing changes, this resource will help you navigate the process effectively.

Follow the steps to complete your membership termination form online.

1. Use the ‘Get Form’ button to access the MEMBERSHIP TERMINATION FORM and open it in the editor.
2. Fill in the month and year for your membership termination at the top of the form. This indicates when your coverage will end.
3. Provide any changes to your billing address in the designated section to ensure accurate correspondence.
4. Enter the group number, along with the city, state, and ZIP code associated with your plan.
5. Complete the group name and contact person information to facilitate future communication.
6. Include the contact phone number and email address for any inquiries related to this termination.
7. Specify the member's name and member ID number to ensure proper identification on the form.
8. Indicate the plan you wish to terminate (medical, dental, vision, or all) and the date that coverage is set to end.
9. Select the reason for termination from the options available, such as resignation, retirement, or moving out of the service area.
10. If applicable, provide the qualifying event code that corresponds to the reason for termination.
11. Fill in the completed by section with your name, title, and the date of submission.
12. After reviewing all the information for accuracy, save your changes. You may choose to download, print, or share the completed form according to your needs.

Complete your MEMBERSHIP TERMINATION FORM online today to ensure a smooth termination process.