Follow the steps to complete your Ameriflex COBRA Request for Service form.

1. Click ‘Get Form’ button to obtain the Ameriflex COBRA Request for Service form online.
2. Provide your participant name and employer name in the designated fields. Ensure that your Member ID or Social Security Number is accurately recorded for identification purposes.
3. Enter your date of birth and current or previous street address, including the state, city, and zip code for accurate correspondence.
4. Fill out your email address and telephone number to ensure you can be contacted regarding your request.
5. If applicable, indicate any address changes by completing the new street address, city, state, and zip fields.
6. If there has been a name change, please provide the new name and include a copy of a legal document, such as a marriage certificate or divorce decree.
7. To add or drop coverage, complete the appropriate section. If dropping all coverage for yourself and dependents, indicate 'Yes' or 'No' and provide the reason for the change.
8. If you are not dropping coverage for all dependents, specify who should be dropped by providing their name, date of birth, gender, and the types of coverage to add or drop (Medical, RX, Dental, Vision, FSA/HRA, etc.).
9. If you need to add or drop more than three family members, complete a second COBRA Request for Service form.
10. If you're adding a newborn, ensure to attach a copy of the crib card or documentation from the hospital including the baby's name, date of birth, height, and weight.
11. Indicate whether you are providing Medicare eligibility documentation, and ensure to include a photocopy of the Medicare ID card if applicable.
12. If requesting a disability extension, mark 'Yes' and attach the photocopy of the Award Letter from the Social Security Administration.
13. Fill in the effective date of your requested changes in the relevant field.
14. Sign the form where indicated and provide the date of signing.
15. Submit your completed form by email to service@myameriflex.com.

Complete your Ameriflex COBRA Request For Service form online to manage your health benefits today.