Fillable Cuesta College - SISC III Membership Change Form

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Cuesta College - SISC III Membership Change Form

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File type: PDF

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DISTRICT USE ONLY (Required)
DISTRICT
N
A
ME
(
Do
abbre
v
iate):
REQUESTED
EFFE
C
TIVE
D
A
TE:
/
/
MEDI
C
A
L
GROUP
N
O.:
DISTRICT
A
PPROVED
INITI
A
LS:
75% OPTION
–
PROVIDE SPOUSE
SOCIAL SECURITY NO.
PRINT CLEARLY IN BLACK OR BLUE INK
SUBSCRIBER CHANGES
SISC III MEMBERSHIP CHANGE FORM
NAME OF SUBSCRIBER LAST NAME (PRINT) FIRST NAME (PRINT) SOCIAL SECURITY NO.
NAME CHANGE
□
Subscriber name only
□
Spouse
□
Domestic Partner
□
Child
OLD NAME(S): LAST NAME (PRINT) FIRST NAME (PRINT)
NEW NAME(S):
SUBSCRIB
E
R
OLD
A
DDRESS
SUBSCRIB
E
R
NEW
A
D
DRESS
Old
A
d
dress
New
Address
Cit
y
/State/Zip
Cit
y
/State/Zip
Old
P
h
one No.
( )
New
Phone
N
o
.
( )
SOCIAL SECURITY NO. AND DATE OF BIRTH CHANGES
□
CHA
NGE
SO
CI
A
L
SE
CURIT
Y
NO.
FOR
:
FRO
M
:
TO:
□
CH
A
N
GE
D
ATE
OF
BIRT
H
FO
R
:
FR
OM:
TO:
DEPENDENT CHANGES Proof of eligibility required (i.e.
birth/marriage/domestic
partner certificate).
District
Use
□
ADD
□
DELETE
□
SPOUSE
□
DOMESTIC
PA
RTNER
□
M
□
F
LAST
NAME
(PRI
N
T
)
FIRST
NAME (PRIN
T
)
MI
SOCIAL
SECUR
I
T
Y
NO.
REASON FOR CHANGE:
□
MEDICAL
□
DENTAL
□
VISION
DA
T
E
OF
BI
R
T
H
/
/
AGE
ELI
G
IBLE
F
O
R
OTHER HEALTH
PLAN?
□
YES
□
NO
ENROLLED
IN
OTHER HEALTH
PLAN?
□
YES
□
NO
IPA
(HMO ONLY
–
REQUIRED)
PCP
(HMO
ONLY
–
R
EQUIRED)
IS
T
HIS
Y
OUR
CURRENT
PROVIDER?
□
YES
□
NO
□
ADD
□
DELETE
□
SON
□
DAUGHTER
LAST
NAME
(PRI
N
T
)
FIRST
NAME (PRIN
T
)
MI
SOCIAL
SECUR
I
T
Y
NO.
REASON FOR CHANGE:
□
MEDICAL
□
DENTAL
□
VISION
DA
T
E
OF
BI
R
T
H
/
/
AGE
ELI
G
IBLE
F
O
R
OTHER HEALTH
PLAN?
□
YES
□
NO
ENROLLED
IN
OTHER HEALTH
PLAN?
□
YES
□
NO
IPA
(HMO ONLY
–
REQUIRED)
PCP
(HMO
ONLY
–
R
EQUIRED)
IS
T
HIS
Y
OUR
CURRENT
PROVIDER?
□
YES
□
NO
□
ADD
□
DELETE
□
SON
□
DAUGHTER
LAST
NAME
(PRI
N
T
)
FIRST
NAME (PRIN
T
)
MI
SOCIAL
SECUR
I
T
Y
NO.
REASON FOR CHANGE:
□
MEDICAL
□
DENTAL
□
VISION
DA
T
E
OF
BI
R
T
H
/
/
AGE
ELI
G
IBLE
F
O
R
OTHER HEALTH
PLAN?
□
YES
□
NO
ENROLLED
IN
OTHER HEALTH
PLAN?
□
YES
□
NO
IPA
(HMO ONLY
–
REQUIRED)
PCP
(HMO
ONLY
–
R
EQUIRED)
IS
T
HIS
Y
OUR
CURRENT
PROVIDER?
□
YES
□
NO
□
ADD
□
DELETE
□
SON
□
DAUGHTER
LAST
NAME
(PRI
N
T
)
FIRST
NAME (PRIN
T
)
MI
SOCIAL
SECUR
I
T
Y
NO.
REASON FOR CHANGE:
□
MEDICAL
□
DENTAL
□
VISION
DA
T
E
OF
BI
R
T
H
/
/
AGE
ELI
G
IBLE
F
O
R
OTHER HEALTH
PLAN?
□
YES
□
NO
ENROLLED
IN
OTHER HEALTH
PLAN?
□
YES
□
NO
IPA
(HMO ONLY
–
REQUIRED)
PCP
(HMO
ONLY
–
R
EQUIRED)
IS
T
HIS
Y
OUR
CURRENT
PROVIDER?
□
YES
□
NO
SUBSCRIBER SIGNATURE DATE
http://sisc.kern.org/hw
MUST BE SUBMITTED WITHIN 30 DAYS OF QUALIFYING EVENT
Rev. 04/14
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Cuesta College - SISC III Membership Change Form

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Completed 23 April 2020

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