Get Change Request Form - Coventryone

Filling out the Change Request Form - CoventryOne online is a straightforward process that allows you to make updates to your coverage. This guide will walk you through each step to ensure your request is completed accurately and efficiently.

Follow the steps to complete the Change Request Form effectively.

1. Press the ‘Get Form’ button to access and open the Change Request Form in your preferred editor.
2. Begin with the 'Underwritten by' section by marking the appropriate box to specify which Coventry entity underwrites your plan.
3. In the 'Primary Member Information' section, fill in your last name, first name, middle initial, member ID number, and primary phone number. Ensure that this information matches what is on your ID card.
4. If you need to change your address or name, complete the 'Address / Name Change' section. Provide both your previous and new name, along with any new contact details.
5. To add a newborn or newly adopted child, navigate to the 'Newborn Addition' section. Fill in all required information including their last name, first name, gender, birthdate, and social security number.
6. For removing or moving dependents, complete the 'Remove / Move Dependents' section by detailing each dependent's full name, birthdate, date of change, and social security number. Indicate the specific change requested.
7. If you are decreasing benefits or cancelling coverage, fill out the respective section, specifying the effective date of the change and the reason for cancellation.
8. Use the 'Other' section to explain any additional changes not covered in the previous sections. Be aware that some changes may require a new application for health coverage.
9. Sign and date the form in the designated areas, ensuring all required signatures are collected from dependent applicants aged 18 and over.
10. After completing the form, you can save your changes, download a copy for your records, or print and share the form as necessary.

Complete your Change Request Form online today to ensure your health coverage reflects your current needs.