Please complete in blue or black ink only.
NEW YORK SMALL GROUP CONTACT/ADDRESS/NAME CHANGE FORM
TTY: 711 • Metroplus Health Plan • 160 Water St., 3rd. Fl. • New York, NY 10038
MBR 18.301 Page 1 of 1
SECTION 1: GROUP IDENTIFICATION
SECTION 2: SMALL GROUP ASSUMPTION AGREEMENT
Any group name or tax identication number change does not end group's obligations, nancial and otherwise,
previously incurred under the terms of its MetroPlus Health Plans Enrollment Agreement. In order to execute a group
contact, address or name change, a signature from a company administrator or authorized party is required:
_______________________________________________ _______________________________________________
Company Administrator or Authorized party signature Printed Name
_______________________________________________ _______________________________ ___________
Title Party’s Phone # Date
Group Name: ______________________________________________________________________________________________
Group Number : _______________________________________ Group Phone #: _____________________________________
Effective Date of Change:
___________
Change in Group‘s Main Business Address*:
Address
____________________________________________________________________________________________________
_
City:
____________________________________________
State:
___________________
Zip Code:
____________
Change in Group‘s Billing Address*:
Address
____________________________________________________________________________________________________
_
City:
____________________________________________
State:
___________________
Zip Code:
____________
Change in Group‘s Benets Administrator or Other Contacts*:
Primary Contact -
Name: _______________________________________________ Title: _______________________________________________
Phone #: ______________________ Fax #: ______________________ Email Address: ________________________________
Secondary Contact -
Name: _______________________________________________ Title: _______________________________________________
Phone #: ______________________ Fax #: ______________________ Email Address: ________________________________
Change in Group‘s Name or Tax ID Number**:
New Group Name:
___________________________________________________________________________________________
_
New Tax ID Number:
____________________________________________
* Please attach proof of new address, such as a utility bill with Company Name / Primary or Secondary Contact.
** Please attach proof of new Name / Tax ID Number, such as ocial tax document displaying new Name / Tax ID Number.
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