Employer
Medical Provider
Address
City, State Zip Code  

Re:      Change of Account Name

 

To whom it may concern:

 

Please be advised that the below client has had a change of name:

 

Current Account Name:

Date of Birth:
Social Security No.:

Group No.:
Member Identification No.:

Memo (optional):

 

Please change the current name on the account to reflect the information below:

 

New Account Name:

 

[ ] This also reflects an address change (check box only if applicable):

 

Address _________________________________________________________________

City _______________________________ State ________ Zip Code ________________

 

[ ] Also, please send me a change of beneficiary form.  (check box only if applicable)

 

I authorize the above-referenced record change(s). If there are any additional forms required,

please send them to the above address.  If there are any questions please do not hesitate to contact me at the above telephone number.

 

Thank you for your assistance.

 

Sincerely,

 

 

 

Print Name

Enclosure: Proof of Legal Name Change