Get 2013 Twin Cities Campus Change, Cancel, Payment, And Dependent Enrollment Form

Filling out the 2013 Twin Cities Campus Change, Cancel, Payment, And Dependent Enrollment Form online is essential for making updates or changes to your AHC Student Health Benefit Plan. This guide provides clear and supportive steps to assist you through the process, ensuring you complete the form accurately and efficiently.

Follow the steps to complete the form online effectively.

1. Click ‘Get Form’ button to acquire the form and open it in your editing tool.
2. Enter your primary member information in Section A. This includes your name, date of birth, gender, University of Minnesota ID number, and contact details like street address and daytime phone number. Specify what action you wish to take regarding your coverage, such as enrolling dependent(s) or canceling coverage.
3. In Section B, select your enrollment options. Indicate which plan you wish to enroll in and provide requisite details for any dependents you want to add. Make sure to fill in all names, dates of birth, gender, and Social Security numbers for each dependent accurately.
4. Complete Section C by signing the authorization to obtain or release medical information. Remember that electronic signatures are not accepted, so you will need to sign manually.
5. In Section E, provide your payment information if applicable. Circle your method of payment and fill in the necessary credit card details along with your authorizing signature. Again, electronic signatures are not permitted.
6. After completing all sections, review your form to ensure all information is accurate. Once satisfied, you can save changes, download, or print a copy of the form for your records.
7. Submit the completed form to the Office of Student Health Benefits at the provided address or via fax or email, as indicated in the instructions.

Complete your documents online today for a smoother process!