COLONIE CHAMBER OF COMMERCE
MVP HEALTH PLAN CHANGE FORM FOR SMALL GROUP
Name Member #
Please note: if you would like to keep your current health plan for 2015, please mark the form as no changes.
NO CHANGES (Please mark box below for Dependent to Age 30 rider-Add or Remove)
If you want to make a change for 2015, you must fill out and return this form By December 1. If you would like help choosing a new plan, call Catherine at the Colonie Chamber at 518-785-6995 ext. 12.
I would like to change my 2015 plan to the plan indicated below.
MVP LIBERTY PLANS (NON-STANDARD)
PLATINUM
GOLD
SILVER
BRONZE
/ Gold 2 HDHP / / Silver 2 / / Bronze 2
/ Gold 3 / / Silver 3 HDHP / / Bronze 3 HDHP
/ Silver 4 HRA / / Bronze 4 HDHP
/ Bronze 5 HDHP
Add Dependent Care to Age 30 Rider
Remove Dependent Care to Age 30 Rider
I would like to cancel my MVP plan as of this date:
If you have children under the age of 19 pediatric dental will automatically be added to your policy unless we have a Pediatric Attestation Form on file indicating they have coverage for this benefit elsewhere.
Please sign and return this completed form by December 1.
Print Name______
Signature ______Date ______
Health benefit plans are issued or administered by MVP Health Plan, Inc.; MVP Health Insurance Company of New Hampshire, Inc.; MVP Health Plan of New Hampshire, Inc.; MVP Select Care, Inc.; MVP Health Services Corp.; Preferred Administrative Services, Inc.; Preferred Assurance Company, Inc.; and Hudson Health Plan, Inc., operating subsidiaries of MVP Health Care, Inc. Not all plans available in all states.
SG CHANGE FORM CHAMBER (10/14)