Instructions for completing Status Change Form 1. Complete all applicable sections. 2. General enrollee information must be filled out completely.General Enrollee InformationMember's Name (as on I.D. card)*Address*Telephone*Member Number (include Group #)Group/Employer's NameChange of Doctor RequestCurrent DoctorFacility #Reason for ChangeNew DoctorFacility #Other Changes RequestedPlease check one of the following options Name Change Address Change New NameNew AddressCityZipDependent(s) to add/deletePlease choose one of the following optionsAddDelete1. NameBirthdate2. NameBirthdate3. NameBirthdate4. NameBirthdateDelete Member(s)1. NameMember #Amount2. NameMember #Amount3. NameMember #Amount4. NameMember #Amount