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Get UHC MS-07-422 REV 8

N be completed online at the employer area of our website www.oxfordhealth.com A. Employer/Employee Information (To be completed by the employer) Group ID Number: Group Name: Employee Insurance ID Number: Employer Signature Employee Name: X / Effective Date B. Transaction Termination Change Address changes can be done online or by calling Oxford. COBRA or State Continuation / / Who : / Reason: Employee Spouse/Partner Dependent(s) NY Young Adult Who: Last Name: First Name: / / .

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