Individual Insurance Coverage Termination Form
Maryland, Washington, D.C., and Northern Virginia
(Not for coverage obtained through the Federal Exchange)
Mail Administrator |
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P.O. Box 14651, Lexington, KY 40512 |
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Fax: 410-505-2901 or toll-free 800-305-1351 |
This is not an application for insurance |
SECTION 1: SUBSCRIBER INFORMATION
Subscriber’s Last Name |
Subscriber’s First Name |
M.I. |
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Residence Address (Street) |
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Residence County |
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Phone Number |
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SECTION 2: PLAN INFORMATION |
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Subscriber ID |
Requested Date to Terminate Plan (mm/dd/yyyy) |
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(Exclude the first three letters from your ID) |
(Unless due to death, date must be the last day of the month you want |
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coverage to end) |
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Select the Plan(s) to be Terminated |
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Medical: Group Number |
Dental: Group Number |
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SECTION 3: REASON FOR TERMINATION
Reason for Termination of Plan (Requested termination date subject to terms and conditions of Subscriber’s member contract)
Coverage too expensive |
Going to Medicare |
Marriage |
Moved out of state/ |
Divorced |
Left employment |
Military coverage |
coverage area |
Elected other coverage |
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Other: |
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Death (You must include a copy of an authorized death certificate with this form.) |
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SECTION 4: SUBSCRIBER/PARENT OR LEGAL GUARDIAN SIGNATURE
FOR OFFICE USE ONLY
Re-sign and re-date below only if checked
We need 7–10 business days to complete your request. Need help? Give us a call! If you need assistance, please call the
Member Service telephone number on the back of your member ID card. Please have your member ID card available.
Where can I find my Member ID Number and Group Number?
1Member ID Number — this is the number providers will ask for to verify your coverage
2Group Number — identifies your plan
Member Name |
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OPEN ACCESS |
JOHN DOE |
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BLUECHOICE HMO HSA BRONZE |
Member ID |
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PCP Name |
ABC000000000 |
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SMITH, JANE |
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Group |
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99K1 |
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RxBIN 004336 RxPCN ADV RxGrp RX7546 |
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P$0 S$0 CC$0 UC$0 ER$50 |
BCBS Plan 080/580 |
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CD$13100 RX AV |
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CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst MedPlus is the business name of First Care, Inc. CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., First Care, Inc., BlueChoice, Inc. and The Dental Network are independent licensees of the Blue Cross and Blue Shield Association.The Blue Cross and Blue Shield Names and Symbols are registered service marks of the Blue Cross and Blue Shield Association.The CareFirst name and logo are registered service marks of Group Hospitalization and Medical Services, Inc. and CareFirst of Maryland, Inc.
CUT9486-1N CDW (6/19)
Individual Insurance Coverage Termination Form Guidelines
Before you start, please note: This form is used to cancel a POLICY. Do not use this form to make changes to your dependents on an existing policy you wish to keep. Use this form to cancel the following health insurance coverage:
■■Medical, dental, vision coverage if you enrolled directly through CareFirst.
■■Medical, dental coverage if you enrolled via the Maryland or DC Health Exchanges.
This form cannot be used to cancel the following health insurance coverage:
■■If you currently have coverage through your employer; you must work with your Human Resources department and/or plan administrator to terminate your coverage.
■■If you enrolled via the Virginia Federal Facilitated Exchange (FFE); please contact the FFE to terminate your coverage.
■■If a subscriber is deceased and he/she enrolled via the Exchange, please contact the appropriate Exchange to cancel subscriber’s policy.
Below is the most recent contact information.
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NAME |
WEBSITE |
CUSTOMER SUPPORT |
MD |
Maryland Health Connection |
marylandhealthconnection.gov |
855-642-8572 |
D.C. |
DC Health Link |
dchealthlink.com |
855-532-5465 |
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VA |
FFE |
HealthCare.gov |
800-318-2596 |
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Termination effective dates
Request cancellation by the last day of the month you want your coverage to end.
Note: If you fail to pay premiums for the coverage period prior to your termination date, your coverage may be terminated
due to non-payment.
Retroactive termination requests
Retroactive terminations, i.e., termination dates in the past, are only permitted in the event of the subscriber’s death. A copy of the subscriber’s death certificate must be submitted with this Termination Form.
Cancelling a termination request
If you submit a termination form but then decide to keep your coverage, it may be possible to withdraw your termination
request. Please note:
■■You cannot withdraw a termination request if you have coverage through the Maryland or DC Health Exchanges.
■■For coverage obtained directly from CareFirst
The withdraw request must be received by CareFirst in writing.
If you are enrolled in a grandfathered plan (you enrolled in a plan before March 23, 2010), you may not be able to re-enroll in that grandfathered plan after coverage is terminated.
Coverage change due to open enrollment
Switching plans during Open Enrollment does NOT automatically cancel your current coverage. Termination requests must be submitted for the following:
■■Changing and switching from an On-Exchange individual plan to an Off-Exchange individual plan—or vice versa.
■■Switching to an employer plan.
■■Changing health insurers.
■■Moving out of state.
If you do not terminate your old plan by December 31, your premium payment for that plan will be due on January 1.
Notice of Nondiscrimination and Availability of Language Assistance Services
(UPDATED 8/5/19)
CareFirst BlueCross BlueShield, CareFirst BlueChoice, Inc., CareFirst Diversified Benefits and all of their corporate affiliates (CareFirst) comply with applicable federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability or sex. CareFirst does not exclude people or treat them differently because of race, color, national origin, age, disability or sex.
CareFirst:
■Provides free aid and services to people with disabilities to communicate effectively with us, such as:
Qualified sign language interpreters
Written information in other formats (large print, audio, accessible electronic formats, other formats)
■Provides free language services to people whose primary language is not English, such as:
Qualified interpreters
Information written in other languages
If you need these services, please call 855-258-6518.
If you believe CareFirst has failed to provide these services, or discriminated in another way, on the basis of race, color, national origin, age, disability or sex, you can file a grievance with our CareFirst Civil Rights Coordinator by mail, fax or email. If you need help filing a grievance, our CareFirst Civil Rights Coordinator is available to help you.
To file a grievance regarding a violation of federal civil rights, please contact the Civil Rights Coordinator as indicated below. Please do not send payments, claims issues, or other documentation to this office.
Civil Rights Coordinator, Corporate Office of Civil Rights
Mailing Address |
P.O. Box 8894 |
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Baltimore, Maryland 21224 |
Email Address |
civilrightscoordinator@carefirst.com |
Telephone Number |
410-528-7820 |
Fax Number |
410-505-2011 |
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at:
U.S. Department of Health and Human Services 200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., CareFirst BlueChoice, Inc., The Dental Network and First Care, Inc. are independent licensees of the Blue Cross and Blue Shield Association. In the District of Columbia and Maryland, CareFirst MedPlus is the business name of First Care, Inc. In Virginia, CareFirst MedPlus is the business name of First Care, Inc. of Maryland (used in VA by: First Care, Inc.). The Blue Cross® and Blue Shield® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
Foreign Language Assistance
Attention (English): This notice contains information about your insurance coverage. It may contain key dates and you may need to take action by certain deadlines. You have the right to get this information and assistance in your language at no cost. Members should call the phone number on the back of their member identification card. All others may call 855-258-6518 and wait through the dialogue until prompted to push 0. When an agent answers, state the language you need and you will be connected to an interpreter.
አማርኛ (Amharic) ማሳሰቢያ፦ ይህ ማስታወቂያ ስለ መድን ሽፋንዎ መረጃ ይዟል። ከተወሰኑ ቀነ-ገደቦች በፊት ሊፈጽሟቸው የሚገቡ ነገሮች ሊኖሩ ስለሚችሉ እነዚህን ወሳኝ ቀናት ሊይዝ ይችላል። ይኽን መረጃ የማግኘት እና ያለምንም ክፍያ በቋንቋዎ እገዛ የማግኘት መብት አለዎት። አባል ከሆኑ ከመታወቂያ ካርድዎ በስተጀርባ ላይ ወደተጠቀሰው የስልክ ቁጥር መደወል ይችላሉ። አባል ካልሆኑ ደግሞ ወደ ስልክ ቁጥር
855-258-6518 ደውለው 0ን እንዲጫኑ እስኪነገርዎ ድረስ ንግግሩን መጠበቅ አለብዎ። አንድ ወኪል መልስ ሲሰጥዎ፣ የሚፈልጉትን ቋንቋ ያሳውቁ፣ ከዚያም ከተርጓሚ ጋር ይገናኛሉ።
Èdè Yorùbá (Yoruba) Ìtẹ́tíléko: Àkíyèsí yìí ní ìwífún nípa iṣẹ́adójútòfò rẹ. Ó le ní àwọn déètì pàtó o sì le ní láti gbé ìgbésẹ̀ní àwọn ọjọ́gbèdéke kan. O ni ẹ̀tọ́láti gba ìwífún yìí àti ìrànlọ́wọ́ní èdè rẹ lọ́fẹ̀ẹ́. Àwọn ọmọ-ẹgbẹ́ gbọ́dọ̀pe nọ́mbà fóònù tó wà lẹ́yìn káàdì ìdánimọ̀wọn. Àwọn míràn le pe 855-258-6518 kí o sì dúró nípasẹ̀ìjíròrò títí a ó fi sọ fún ọ láti tẹ 0. Nígbàtí aṣojú kan bá dáhùn, sọ èdè tí o fẹ́a ó sì so ọ́pọ̀mọ́ògbufọ̀kan.
Tiếng Việt (Vietnamese) Chú ý: Thông báo này chứa thông tin về phạm vi bảo hiểm của quý vị. Thông báo có thể chứa những ngày quan trọng và quý vị cần hành động trước một số thời hạn nhất định. Quý vị có quyền nhận được thông tin này và hỗ trợ bằng ngôn ngữ của quý vị hoàn toàn miễn phí. Các thành viên nên gọi số điện thoại
ởmặt sau của thẻ nhận dạng. Tất cả những người khác có thể gọi số 855-258-6518 và chờ hết cuộc đối thoại cho đến khi được nhắc nhấn phím 0. Khi một tổng đài viên trả lời, hãy nêu rõ ngôn ngữ quý vị cần và quý vị sẽ được kết nối với một thông dịch viên.
Tagalog (Tagalog) Atensyon: Ang abisong ito ay naglalaman ng impormasyon tungkol sa nasasaklawan ng iyong insurance. Maaari itong maglaman ng mga pinakamahalagang petsa at maaaring kailangan mong gumawa ng aksyon ayon sa ilang deadline. May karapatan ka na makuha ang impormasyong ito at tulong sa iyong sariling wika nang walang gastos. Dapat tawagan ng mga Miyembro ang numero ng telepono na nasa likuran ng kanilang identification card. Ang lahat ng iba ay maaaring tumawag sa 855-258-6518 at maghintay hanggang sa dulo ng diyalogo hanggang sa diktahan na pindutin ang 0. Kapag sumagot ang ahente, sabihin ang wika na kailangan mo at ikokonekta ka sa isang interpreter.
Español (Spanish) Atención: Este aviso contiene información sobre su cobertura de seguro. Es posible que incluya fechas clave y que usted tenga que realizar alguna acción antes de ciertas fechas límite. Usted tiene derecho a obtener esta información y asistencia en su idioma sin ningún costo. Los asegurados deben llamar al número de teléfono que se encuentra al reverso de su tarjeta de identificación. Todos los demás pueden llamar al 855-258-6518 y esperar la grabación hasta que se les indique que deben presionar 0. Cuando un agente de seguros responda, indique el idioma que necesita y se le comunicará con un intérprete.
Русский (Russian) Внимание! Настоящее уведомление содержит информацию о вашем страховом обеспечении. В нем могут указываться важные даты, и от вас может потребоваться выполнить некоторые действия до определенного срока. Вы имеете право бесплатно получить настоящие сведения и сопутствующую помощь на удобном вам языке. Участникам следует обращаться по номеру телефона, указанному на тыльной стороне идентификационной карты. Все прочие абоненты могут звонить по номеру 855-258-6518 и ожидать, пока в голосовом меню не будет предложено нажать цифру «0». При ответе агента укажите желаемый язык общения, и вас свяжут с переводчиком.
हिन्दी (Hindi) ध्यान दें: इस सचनाू मेंआपकी बीमा कवरेजकेबारेमेंजानकारी दी गई िै।िो सकता िैकक इसमेंख्यु ततथियों का उल्लेखिो और आपकेललए ककसी तनयत समय-सीमा केभीतर काम करना ज़रूरी िो। आपको यि जानकारी और संबंथितसिायता अपनी भाषा मेंतनिःशल्कु पानेका अथिकार िै।सदस्यों को अपनेपिचान पत्र केपीछेहदए गए फोन नंबरपर कॉल करना चाहिए। अन्य सभी लोग 855-258-6518 पर कॉल कर सकतेिैंऔर जब तक 0 दबानेकेललए न किा जाए, तब तक संवादकी प्रतीक्षा करें।जब कोई एजेंटउत्तर देतो उसेअपनी भाषा बताएँऔर आपको व्याख्याकार सेकनेक्ट
कर हदया जाएगा। |
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wa mo! B ̃̌nyu nyu hw |
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fuà ṹá tìǐ |
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বাাংলা (Bengali) লক্ষ্য করুন: এই ননাটিশে আপনার ববমা কভাশরজ সম্পশকেতথ্য রশেশে। এর মশযয গুরুত্বপূর্েতাবরখ থ্াকশত পাশর এবাং বনবদেষ্টতাবরশখর মশযয আপনাশক পদশক্ষ্প বনশত হশত পাশর। ববনা খরশে বনশজর ভাষাে এই তথ্য পাওোর এবাং সহােতা পাওোর অবযকার আপনার আশে। সদসযশদরশক তাশদর পবরেেপশের বপেশন থ্াকা নম্বশর কল করশত হশব। অশনযরা 855-258-6518 নম্বশর কল কশর 0 টিপশত না বলা পর্েন্তঅশপক্ষ্া করশত পাশরন। র্খন নকাশনা এশজন্ট উত্তর নদশবন তখন আপনার বনশজর ভাষার নাম বলুন এবাং আপনাশক নদাভাষীর সশে সাংর্ুক্তকরা হশব।
نکمم روا ںیہ یتکس وہ ںیخیرات یدیلک ںیم سا ۔ےہ لمتشم رپ تامولعم قلعتم ےس جیروک سنیروشنا ےک پآ سٹون ہی: ہجوت )Urdu( ودرا ہچرخ ریغب روا ےنرک لصاح تامولعم ہی ساپ ےک پآ ۔ےڑپ ترورض یک ےنرک یئاورراک کت ںوخیرات یرخآ صوصخم وک پآ ہک ےہ رگید یھبس ۔ےیہاچ ینرک لاک رپ ربمن نوف دوجوم رپ تشپ یک ڈراک یتخانش ےنپا وک ناربمم ۔ےہ قح اک ےنرک لصاح ددم ںیم نابز ینپا ےیک نابز ہبولطم ینپا رپ ےنید باوج ےک ٹنجیا ۔ںیرک راظتنا کت ےناج ےہک وک ےنابد 0 روا ںیہ ےتکس رک لاک رپ855-258-6518 گول ۔ےگ ںیئاج وہ طوبرم ےس مجرتم روا ںیئاتب
خیرات ات تسا مزلا و دشاب یمھم یاه خیرات یواح تسا نکمم .تسا امش همیب ششوپ هرابرد یتاعلاطا یواح هیملاعا نیا :هجوت )Farsi( یسراف
.دینک تفایرد ناتدوخ نابز هب ناگیار تروص هب ار ییامنهار و تاعلاطا نیا ات دیتسه رادروخرب قح نیا زا امش .دینک مادقا یصاخ هدش ررقم هرامش اب دنناوت یم دارفا ریاس .دنریگب سامت ناشییاسانش تراک تشپ رد هدش جرد هرامش اب دیاب اضعا نابز ،اهروتارپا زا یکی طسوت ییوگخساپ زا دعب .دنهد راشف ار 0 ددع دوش هتساوخ اھنآ زا ات دننامب رظتنم و دنریگب سامت855-258-6518
.دیوش لصو هطوبرم مجرتم هب ات دینک میظنت ار زاین دروم
ذاختا ىلإ جاتحت دقو ،ةمھم خیراوت ىلع يوتحی دقو ،ةینیمأتلا كتیطغت نأشب تامولعم ىلع راطخلإا اذه يوتحی: هیبنت (Arabic) ةیبرعلا ةغللا لاصتلاا ءاضعلأا ىلع يغبنی. ةفلكت يأ لمحت نودب كتغلب تامولعملاو ةدعاسملا هذه ىلع لوصحلا كل قحی. ةددحم ةیئاھن دیعاوم لولحب تاءارجإ مقرلا ىلع لاصتلاا نیرخلآل نكمی. مھب ةصاخلا ةیوھلا فیرعت ةقاطب رھظ يف روكذملا فتاھلا مقر ىلع اھب لصاوتلا ىلإ جاتحت يتلا ةغللا ركذا ،ءلاكولا دحأ ةباجإ دنع 0. مقر ىلع طغضلا مھنم بلطی ىتح ةثداحملا للاخ راظتنلااو 855-258-6518
.نییروفلا نیمجرتملا دحأب كلیصوت متیسو
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Igbo (Igbo) Nrụbama: Ọkwa a nwere ozi gbasara mkpuchi nchekwa onwe gị. Ọ nwere ike ịnwe ụbọchị ndị dị mkpa, ị nwere ike ịme ihe tupu ụfọdụ ụbọchị njedebe. Ị nwere ikike ịnweta ozi na enyemaka a n’asụsụ gị na akwụghị ụgwọ ọ bụla. Ndị otu kwesịrị ịkpọ akara ekwentị dị n’azụ nke kaadị njirimara ha. Ndị ọzọ niile nwere ike ịkpọ 855-258-6518 wee chere ụbụbọ ahụ ruo mgbe amanyere ịpị 0. Mgbe onye nnọchite anya zara, kwuo asụsụ ị chọrọ, a ga-ejikọ gị na onye ọkọwa okwu.
Deutsch (German) Achtung: Diese Mitteilung enthält Informationen über Ihren Versicherungsschutz. Sie kann wichtige Termine beinhalten, und Sie müssen gegebenenfalls innerhalb bestimmter Fristen reagieren. Sie haben das Recht, diese Informationen und weitere Unterstützung kostenlos in Ihrer Sprache zu erhalten. Als Mitglied verwenden Sie bitte die auf der Rückseite Ihrer Karte angegebene Telefonnummer. Alle anderen Personen rufen bitte die Nummer 855-258-6518 an und warten auf die Aufforderung, die Taste 0 zu drücken. Geben Sie dem Mitarbeiter die gewünschte Sprache an, damit er Sie mit einem Dolmetscher verbinden kann.
Français (French) Attention: cet avis contient des informations sur votre couverture d'assurance. Des dates importantes peuvent y figurer et il se peut que vous deviez entreprendre des démarches avant certaines échéances. Vous avez le droit d'obtenir gratuitement ces informations et de l'aide dans votre langue. Les membres doivent appeler le numéro de téléphone figurant à l'arrière de leur carte d'identification. Tous les autres peuvent appeler le 855-258-6518 et, après avoir écouté le message, appuyer sur le 0 lorsqu'ils seront invités à le faire. Lorsqu'un(e) employé(e) répondra, indiquez la langue que vous souhaitez et vous serez mis(e) en relation avec un interprète.
한국어(Korean) 주의: 이 통지서에는 보험 커버리지에 대한 정보가 포함되어 있습니다. 주요 날짜 및 조치를 취해야 하는 특정 기한이 포함될 수 있습니다. 귀하에게는 사용 언어로 해당 정보와 지원을 받을 권리가 있습니다. 회원이신 경우 ID 카드의 뒷면에 있는 전화번호로 연락해 주십시오. 회원이 아니신 경우 855-258-6518 번으로 전화하여 0을 누르라는 메시지가 들릴 때까지 기다리십시오. 연결된 상담원에게 필요한 언어를 말씀하시면 통역 서비스에 연결해 드립니다.
(Navajo)
855-258-6518
