Get Status Change Request Form - Dartmouth

The Status Change Request Form is essential for requesting changes to your benefits due to a qualified status event. This guide provides a clear and thorough walkthrough of each section of the form to ensure you can complete it efficiently and accurately.

Follow the steps to successfully complete the Status Change Request Form.

1. Press the 'Get Form' button to access the Status Change Request Form and open it in your preferred document editor.
2. Provide your full name, Social Security number, email address, and a reachable phone number during business hours. Indicate your pay schedule by selecting either Monthly or Biweekly.
3. Specify whether you are adding or canceling coverage. If there are benefits you do not wish to change, leave that information blank.
4. Select the level of coverage you wish to change. This includes whether it's for yourself or your dependents, and identify the type of coverage (e.g., Medical insurance) and plan option (e.g., Open Access Plan 1 or High Deductible Health Plan).
5. Fill in the 'Date of Event' field with the date of the qualified event that allows for changes to your benefits (e.g., your wedding date if you got married). Remember, changes can only be requested within 30 days of this event.
6. Indicate the 'Effective Date of Change,' which can be the event date or the first day of the next month, based on your preference for when the changes take effect.
7. List any dependents whose coverage you wish to add, cancel, or change. Only include names of dependents directly affected by your request. If you are adding a newborn, submit the form without the Social Security number, and provide it upon receipt of the child's Social Security card.
8. Sign and date the front of the form to certify your request.
9. On the back of the form, check off the qualifying event that applies to your request. If your event is not listed, it may not qualify for a coverage change. For clarification, contact the Benefits Office.
10. Submit the completed form to the Health Benefits Office through mail, fax, or email. Ensure you use your Dartmouth email address for submissions via email to ensure acceptance.
11. Once submitted, note that processing times can vary, but most requests are completed within 5-10 business days. You will receive an email confirming receipt and the outcome of your request.

Start filling out your Status Change Request Form online today to ensure your benefits are up to date.