Status Change | Vision Plan of America

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)*
Address*
Telephone*
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

General Enrollee Information