Status Change

Online Forms

Instructions for completing Status Change Form

1. Complete all applicable sections.

2. General enrollee information must be filled out completely.

General Enrollee Information

Member's Name (as on I.D. card)(Required)

Address(Required)

Telephone(Required)

Member Number (include Group #)

Group/Employer's Name

Change of Doctor Request

Current Doctor

Facility #

Reason for Change

New Doctor

Facility #

Other Changes Requested

Please check one of the following options

Name Change

Address Change

New Name

New Address

City

Zip

Dependent(s) to add/delete

Please choose one of the following options

Add

Delete

1. Name

Birthdate

2. Name

Birthdate

3. Name

Birthdate

4. Name

Birthdate

Delete Member(s)

1. Name

Member #

Amount

2. Name

Member #

Amount

3. Name

Member #

Amount

4. Name

Member #

Amount

Knox-Keene licensed specialized vision HMO — serving California since 1986

800-400-4872

Status Change

General Enrollee Information

Change of Doctor Request

Other Changes Requested

Dependent(s) to add/delete

Delete Member(s)

Links