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Get CareFirst CUT9486-1N CDW 2014

Membership Cancellation Form Maryland District of Columbia and Northern Virginia Individual Plans CareFirst of Maryland Inc. 10455 Mill Run Circle Owings Mills MD 21117 Group Hospitalization and Medical Services Inc. CareFirst BlueChoice Inc. 840 First Street NE Washington DC 20065 Mailroom Administrator P. O. Box 14651 Lexington KY 40512 800-305-1351 Fax 410-505-2901 This is not an application for insurance If you originally bought insurance directly through the Maryland District of Columbia or Virginia Exchange then you must make changes through that same Exchange. Name of Plan to Cancel Subscriber s Last Name Subscriber s First Name Residence Address Street City and State Residence County Phone Number Subscriber Group Number of plan being cancelled Subscriber Member Number of plan being cancelled Requested Date to Cancel Plan mm/dd/xxxx Reason for Cancellation of Plan / Zip Code Where can I find my Member Number and Group Number M. I. M ember ID this is the number providers will ask for to verify your coverage Member Name JOHN DOE Member ID ABC000000000 Group identifies your plan 2. 0 OPEN ACCESS HealthyBlue Platinum PCP Name Smith Jane Group 99K1 RxBIN 004336 RxPCN ADV RxGrp RX7546 BCBS Plan 080/580 Copay D0 P0 S30 ER200 RX AV We need 7 10 business days to complete your request and will follow-up with you by letter to confirm this request. If you need assistance please call the Member Services telephone number on the back of your member ID card. Our service hours are Monday Friday from 8 00 am 6 00 pm* So that we may serve you as quickly as possible please have your ID card available. REQUIRED SIGNATURE AND DATE Subscriber s Signature Date mm/dd/xxxx Registered trademark of the Blue Cross and Blue Shield Association* Registered trademark of CareFirst of Maryland Inc* CUT9486-IN 9/14. O. Box 14651 Lexington KY 40512 800-305-1351 Fax 410-505-2901 This is not an application for insurance If you originally bought insurance directly through the Maryland District of Columbia or Virginia Exchange then you must make changes through that same Exchange. Name of Plan to Cancel Subscriber s Last Name Subscriber s First Name Residence Address Street City and State Residence County Phone Number Subscriber Group Number of plan being cancelled Subscriber Member Number of plan being cancelled Requested Date to Cancel Plan mm/dd/xxxx Reason for Cancellation of Plan / Zip Code Where can I find my Member Number and Group Number M. Name of Plan to Cancel Subscriber s Last Name Subscriber s First Name Residence Address Street City and State Residence County Phone Number Subscriber Group Number of plan being cancelled Subscriber Member Number of plan being cancelled Requested Date to Cancel Plan mm/dd/xxxx Reason for Cancellation of Plan / Zip Code Where can I find my Member Number and Group Number M. I. M ember ID this is the number providers will ask for to verify your coverage Member Name JOHN DOE Member ID ABC000000000 Group identifies your plan 2. I. M ember ID this is the number providers will ask for to verify your coverage Member Name JOHN DOE Member ID ABC000000000 Group identifies your plan 2. 0 OPEN ACCESS HealthyBlue Platinum PCP Name Smith Jane Group 99K1 RxBIN 004336 RxPCN ADV RxGrp RX7546 BCBS Plan 080/580 Copay D0 P0 S30 ER200 RX AV We need 7 10 business days to complete your request and will follow-up with you by letter to confirm this request. .

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