Get Confidential Communication Request Form ... - Axa

The CONFIDENTIAL COMMUNICATION REQUEST FORM ... - AXA allows individuals covered by health insurance to request communication of claim-related information through alternative means or at alternative locations. This guide provides you with clear, step-by-step instructions for completing the form online.

Follow the steps to fill out your form accurately.

1. Use the ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. In Section A, enter your name, birth date, member I.D., and your relationship to the primary insured or subscriber. Ensure that all information is accurate.
3. Move to Section B. Read the provided information thoroughly. In the designated fields, specify the alternative means of receiving communications due to safety concerns. If you're using another person's address, include their name in the 'In care of' field.
4. Fill in your alternative address, phone number, and email address. This information will be used for future communications regarding your claims.
5. Sign and date the form in the respective fields to confirm your request.
6. If applicable, complete Section C with the parent or guardian's name, relationship to the covered individual, or the legal representative’s details as necessary.
7. Review your completed form for accuracy. Make any necessary edits before finalizing.
8. Save your changes, download, or print the form. Finally, submit the completed form by mailing it to AXA Equitable at the provided address or faxing it to the specified number.

Complete your CONFIDENTIAL COMMUNICATION REQUEST FORM online today for secure and confidential communication.