Get Member Termination Form

Filling out the MEMBER TERMINATION FORM online is a straightforward process designed to efficiently manage the termination of benefit plans. This guide provides step-by-step instructions to help users complete the form accurately and ensure proper processing.

Follow the steps to complete the MEMBER TERMINATION FORM online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter group information by providing the group name and the eight-digit group/division number. Include the name of the person preparing the form and their contact phone number.
3. In the termination information section, list one subscriber per row. For each person being terminated, provide their member ID and full name. Select the appropriate relationship to the subscriber (Subscriber, Spouse/Civil Union Partner, or Dependent). Be aware that selecting 'Subscriber' will terminate the plan for the whole family.
4. Indicate the plan termination date by providing the month and year. Note that the termination date will be effective on the last day of the chosen month.
5. Ensure that the form is signed and dated by an authorized group administrator. This step is crucial for validation.
6. Once all fields are completed, save changes, download, print, or share the form as needed. Ensure that you follow the submission instructions for faxing or mailing the completed form to UHA Employer Services.

Complete the MEMBER TERMINATION FORM online to ensure a smooth termination process.