Get Form B1 - Cchp

Filling out the Form B1 - CCHP online is an important task for managing employee disenrollment. This guide provides clear, step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to complete the Form B1 - CCHP online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the group name and group number in the designated fields at the top of the form.
3. Specify the disenrollment effective date by filling in the last day of the month for the disenrollment.
4. List the member(s) to be disenrolled by entering their last name, first name, middle initial, date of birth, and member ID number for each individual.
5. Select the appropriate disenrollment reason from the provided options. Ensure you choose the most applicable reason for each member.
6. If you select 'Other Termination,' please provide a brief description of the reason in the space provided.
7. Review all entered information for accuracy to ensure that the changes can be processed smoothly.
8. Sign the form by entering the employer or broker name and providing a signature in the designated area.
9. Complete the CCHP use only section at the bottom if required, noting the date of submission.
10. Once all fields are filled correctly, save changes, download, print, or share the completed form as needed.

Start filling out your Form B1 - CCHP online today to manage employee disenrollment effectively.