Ad need to terminate your carefirst contract? View form (applies to all plans) proof of coverage. Web this form is used to request that your insurer terminate the restriction on your protected health information (phi). Protected health information (phi) authorization form for information release. For residents of maryland who purchased a medplus medigap plan with an effective date of august 1, 2016 or later. Web for questions concerning your membership and benefits, or to obtain other fep forms, contact member services at the telephone number on your id card or visit www.fepblue.org. Medical, dental coverage if you enrolled via the maryland or dc health exchanges. Minor vaccination consent notification form. Medical, dental, vision coverage if you enrolled directly through carefirst. Inmediate delivery of your cancellation letter with proof of mailing.
Medical, dental coverage if you enrolled via the maryland or dc health exchanges. Web membership termination form maryland, district of columbia and northern virginia individual plans mailroom administrator p.o. Web this form is used to request that your insurer terminate the restriction on your protected health information (phi). View form (applies to all plans) proof of coverage. Days from the date of your termination letter. For residents of maryland who purchased a medplus medigap plan with an effective date of august 1, 2016 or later. Medical, dental, vision coverage if you enrolled directly through carefirst. Box 14651, lexington, ky 40512fax: This form cannot be used to cancel the following health insurance coverage: Web plan termination view form (applies to all plans) proof of coverage social security number submission form Web reinstatement request form and make payment of all past and currently due premiums.
