Get Production English Version. Facets Enrollment Change Form

Filling out the Production English Version. Facets Enrollment Change Form is essential for users who need to make changes to their enrollment status. This guide provides clear and supportive instructions to help you complete the form accurately and efficiently online, ensuring that your enrollment reflects your current needs.

Follow the steps to complete the form successfully.

1. Press the ‘Get Form’ button to access the Enrollment Change Form and open it in your preferred online editor.
2. In Section A, provide the effective date of the change. Enter the date in the format MM/DD/YYYY and select the appropriate type of change from the options available, including 'New Enrollment' or 'Change'.
3. In Section B, specify your personal information as the employee. Fill in your last name, first name, employee date of birth, and the date of hire, ensuring accuracy to avoid any processing delays.
4. For dependent information in Section C, list any dependents you wish to add or change by providing their names and relationships. Include their social security numbers and dates of birth.
5. Section D requires you to choose your medical options. Select the plans you want, indicating whether you want coverage for yourself and your dependents.
6. In Section E and F, select your dental options, ensuring you maintain clarity on what coverage you wish to receive.
7. Complete the health history section by honestly answering whether you or your dependents have had any significant health issues in the past five years. Provide necessary details if applicable.
8. Review the provided disclosures and ensure you understand them. You will need to sign and date the form in this section to confirm your acknowledgment.
9. After filling in all necessary sections, you can save changes, download a copy for your records, print it out, or share the form as needed.

Start your online form completion today to ensure your enrollment changes are processed smoothly.