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W, a belated enrollment, change, or cancellation must be retroactive to the effective date it would originally have been, had the request for the change been received within the eligible time frame. u If the change results in past due premiums, Federal law states that these premiums must be paid by direct bill. Failure to make this direct bill payment will result in a termination of your enrollment. Section C: Signature and Mailing/Fax Instructions Print name (Required) Signature (Required.

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