Get Add/change/delete Form - Careconnect

Filling out the Add/Change/Delete Form - CareConnect online is a straightforward process that allows users to efficiently manage their insurance information. This guide provides step-by-step instructions to ensure you complete the form accurately and effectively.

Follow the steps to complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the individual's information in section A. Fill out the fields for 'Member Insurance ID Number,' 'Group ID Number,' 'Member ID Number,' 'Member Name,' 'Group Name,' and add the necessary signatures and dates. Make sure to clearly identify whether you are representing an individual or a group.
3. In section B, detail the transaction type you are requesting. Select 'Addition,' 'Termination,' or 'Change' and provide the necessary reasons. Fill in the personal details of the individuals involved, including names, effective dates, and any relevant reasons for the change, such as 'Open Enrollment' or 'Loss of Coverage.'
4. Proceed to section C, where additional information for employees, spouses, or dependents is required. Ensure to include all pertinent details such as Social Security numbers, birthdays, and gender for each individual. Also, provide the primary care physician's name and confirm if they are actively employed.
5. If applicable, complete section D for the coordination of benefits. Indicate Medicare parts and provide policy numbers and effective dates as necessary. Be thorough to avoid any delays in processing your form.
6. Review all information entered. Once all sections are complete and accurate, you can save changes, download the form, print it, or share it as necessary. Make sure to follow the instructions provided for returning the form to CareConnect.

Complete and submit your Add/Change/Delete Form online today to ensure your insurance information is up to date.