Multiple Employee/Member Termination Form

Multiple Employee/Member Termination Form
From (Name of Employer Group)
HMO Group Number
Submitted by (Signature) Telephone Number
( ) -
X
Traditional Control Number Print Name of Authorized Employer Representative Date
First and Last Name Social Security Number Member ID Number E,ective Date of
Termination
Termination
Reason Code.
(See below.)
CSA Comments (optional)
1.
2.
3.
4.
5.
6.
7.
8.
9.
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
termination.
Please make a copy for your records.
GR-67404 (4-14) R-POD E
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