Multiple Employee/Member Termination Form
From (Name of Employer Group)
HMO Group Number
Submitted by (Signature) Telephone Number
( ) -
Traditional Control Number Print Name of Authorized Employer Representative Date
First and Last Name Social Security Number Member ID Number E,ective Date of
CSA Comments (optional)
TERMINATION CODES: C=Changed Health Plan, D=Death, DIS=Disability, L=Layo,, M=Medicare, R=Resignation, RH=Reduction in Hours, S=Student Status
Change, T=Termination, DI=Divorce or Legal Separation, N=Nonpayment
If unable to determine the reason for the termination, use “T”.
* NOTE: If an employee and entire family are being terminated from the plan, it is only necessary to list the employee information on the form for
Please make a copy for your records.
GR-67404 (4-14) R-POD E