Dental Change Form - Arkansas Blue Cross And Blue Shield
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Change Form
Return To: Arkansas Blue Cross and Blue Shield, Attn: Change Request, P.O. Box 2181, Little Rock, AR 72203-2181
or Fax to: 501-378-2236
1 CURRENT POLICYHOLDER INFORMATION
Member ID:_____________________ Group Number:________________ Date of Birth: ____/___/_______
First Name:________________________ M.I.:______ Last Name: ________________________________
Primary Phone Number.: _______________________ Alternate Phone Number.: _____________________
CHANGES TO BE MADE
Please skip sections that do not apply to the change(s) you are making.
2 ADDRESS CHANGES
Residential Address:
Street ___________________________________________________________
City ________________________________ State_________ Zip____________
Mailing Address:
Street ___________________________________________________________
City ________________________________ State_________ Zip____________
Billing Address:
Street ___________________________________________________________
City ________________________________ State_________ Zip____________
3 NAME CHANGE
From:
First Name ________________________ M.I.______ Last Name _________________________
To:
First Name ________________________ M.I.______ Last Name _________________________
Is this name change as a result of a marriage?
o Yes
o No
Marriage Date: ____/____/______
Is this name change as a result of a divorce?
o Yes
o No
Divorce Date: _ ___/____/______
Other reason for change:______________________________
Date of Change: ____/____/______
4 BILLING CHANGE
Monthly Bank Draft
Quarterly Invoice
Semi-Annual Invoice
Annual Invoice
(Must complete attached bank draft form)
5 DELETE PERSON(S) FROM THE POLICY
Reason Code*
Last Name
Date of Birth
Date of Change
First Name
M.I.
Suffix
(see below)
*
Reason Codes:
1 - Divorce
2 - Aging Off
3 - Marriage
4 - Death
5 - Other
Page 1
Non-Under DentalChgFm (R01/12)
(Continued on page 2)
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Parent category: Medical