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 identication 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 Benets 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 ocial tax document displaying new Name / Tax ID Number.
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