Get 2014 Benefits & Information Change Form

This guide provides comprehensive instructions for users on how to effectively complete the 2014 Benefits & Information Change Form online. The form is essential for managing changes to health benefits and premiums.

Follow the steps to accurately fill out the form online.

1. Press the ‘Get Form’ button to access the form and open it in the online editor.
2. Fill in the 'Name of Plan you are enrolling in' at the top of the form.
3. Provide your personal details: input your full name, home phone number, permanent street address, mailing address (note that P.O. Box is not acceptable), and city, state, and zip code.
4. Enter your member number in the designated field.
5. Complete the section confirming your current membership by stating the plan you are in and noting the monthly premium.
6. Indicate the plan you wish to change to, along with the understanding of the different health benefits it offers and the new monthly premium.
7. Select one of the six plans by marking the corresponding checkbox. If needed, refer to the Summary of Benefits for additional details regarding each plan.
8. Input the name of your chosen Primary Care Physician (PCP), clinic, or health center, along with the physician code number.
9. If desired, select a preference for receiving information in another language or format such as Spanish, Braille, or audio tape.
10. Select your preferred payment option for the monthly plan premium: getting a bill, paying online, ZipCheck from your bank account, or automatic deduction from your Social Security or Railroad Retirement Board Check.
11. Read the important information sections carefully and provide your electronic signature and the date when needed.
12. If you are an authorized representative, complete the additional fields regarding your information and relationship to the enrollee.
13. Review the entire form for any errors, then save the changes, download, print, or share it as necessary.

Now is the time to complete your documents online for a seamless experience.