We Pay For Your Medical Costs That
Health Insurance Or Medicare Will Not
Broker Name
Broker Code
Addition/ Termination/ Change Form
A. MEMBER /EMPLOYER INFORMATION
MEMBER NAME (First, Middle Initial, Last)
EMPLOYER COMPANY NAME (If Applicable)
B. TRANSACTION
EFFECTIVE DATE
REQUIRED INFORMATION
ADDITION
MM
DD
YYYY
WHO:
MEMBER
TERMINATION
MM
DD
YYYY
WHO:
MEMBER (DOB:______________)
SPOUSE
CHANGE
MM
DD
YYYY
WHO:
MEMBER
DEPENDENT(S)
COMPLETE ALL Of Section C
DO NOT Have To Complete Section C
COMPLETE ALL Of Section C
C. ADDITIONAL INFO
MEMBER
SPOUSE
SPOUSE
DEPENDENT(S)
SPOUSE
DEPENDENT
DEPENDENT(S)
DEPENDENT
DEPENDENT
/
/
FIRST NAME, MI:
LAST NAME:
DATE OF BIRTH (MM/DD/YYYY):
GENDER
/
/
MALE
/
FEMALE
/
MALE
/
FEMALE
/
MALE
FEMALE
/
MALE
FEMALE
/
MALE
FEMALE
STREET ADDRESS:
APT/STE:
CITY:
STATE ABBREVIATION, ZIP CODE:
SOCIAL SECURITY NUMBER:
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
PHONE NUMBER:
EMAIL ADDRESS:
PRODUCT:
HMA®
HMRA®
CURRENT PLAN:
2500
5000
7500
10000
15000
20000
25000
30000
40000
50000
60000
NEW PLAN CHANGE:
2500
5000
7500
10000
15000
20000
25000
30000
40000
50000
60000
By signing below, I certify the above is complete and correct. Failure to complete and sign this form will prevent your request. If this is a salary reduction employee please attach the Salary Reduction Agreement.
MEMBER SIGNATURE: _________________________________________________________________ DATE: ________ / ________ / ____________
EMPLOYER SIGNATURE (IF APPLICABLE) : _______________________________________________ DATE: ________ / ________ / ____________
ATCF-042021-V13
5120 Woodway Drive, Suite 10025, Houston, Texas 77056 | www.healthmatchingaccounts.com
Tel: (713) 850-8534 Fax: (713) 850-8579
Revised Date: 04/20/21