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Individual Member Voluntary Termination Form Please use this form for Individual Plan member terminations. If you have any questions please call Presbyterian Customer Service Center at 505-923-5678 or toll-free 1-800-356-2219 Monday through Friday 7 00 am 6 00 pm. RETURN INFORMATION Email enrollmentdept phs. Individual Member Voluntary Termination Form Please use this form for Individual Plan member terminations. If you have any questions please call Presbyterian Customer Service Center at 505-923-5678 or toll-free 1-800-356-2219 Monday through Friday 7 00 am 6 00 pm* RETURN INFORMATION Email enrollmentdept phs. org Fax 505 923-8252 MEMBER INFORMATION Member ID Primary Policy Holder s Name Address Mail Presbyterian Health Plan Inc* P. O. Box 27489 Albuquerque NM 87125-7489 Social Security Number City/State Zip Code Phone Number TERMINATION REQUEST Members enrolled on an Exchange/Marketplace Plan Group IN500000 may only request to terminate the Entire Policy. If you need to only terminate a dependent please contact the Exchange/Marketplace directly at 1-800-318-2596. Subscriber Only Spouse/Dependents will keep coverage with Bank or Credit Card Authorization on file New Bank or Credit Card Authorization DOB Last Name MI Gender Relationship to Subscriber Requested Termination Date MM/DD/YY Month/Year Entire Policy - All members Spouse and/or Dependents Only complete section below First Name REASON FOR TERMINATING POLICY Rates too high Moved to another carrier Dissatisfied with service Eligible for Employer group coverage or Medicare with Presbyterian Moved out of service area Effective date I understand terminations are effective on the last day of the month only. I understand that if this form is received on or before the 25th of the month coverage will terminate at the end of the same month. If this form is received after the 25th of the month coverage will terminate at the end of the following month. I understand that submission of this form is not a guarantee that the premium draft will be cancelled by the 25th of the month or following business day. Print Name of Policy Holder or legal guardian MPC051451 x Signature Required of Policy Holder or legal guardian Today s Date INDTERMFORM REV6/2014. If you have any questions please call Presbyterian Customer Service Center at 505-923-5678 or toll-free 1-800-356-2219 Monday through Friday 7 00 am 6 00 pm* RETURN INFORMATION Email enrollmentdept phs. org Fax 505 923-8252 MEMBER INFORMATION Member ID Primary Policy Holder s Name Address Mail Presbyterian Health Plan Inc* P. org Fax 505 923-8252 MEMBER INFORMATION Member ID Primary Policy Holder s Name Address Mail Presbyterian Health Plan Inc* P. O. Box 27489 Albuquerque NM 87125-7489 Social Security Number City/State Zip Code Phone Number TERMINATION REQUEST Members enrolled on an Exchange/Marketplace Plan Group IN500000 may only request to terminate the Entire Policy. O. Box 27489 Albuquerque NM 87125-7489 Social Security Number City/State Zip Code Phone Number TERMINATION REQUEST Members enrolled on an Exchange/Marketplace Plan Group IN500000 may only request to terminate the Entire Policy. If you need to only terminate a dependent please contact the Exchange/Marketplace directly at 1-800-318-2596.

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