Medical Plan Name Change Form - Your Online Wedding Planning Guide and Resource

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Inside Name Change

	Introduction, before you begin
	Name change tools
	Social Security
	U.S. Post Office
	Internal Revenue Service
	U.S. Passport Agency
	Department of Motor Vehicles (drivers license, vehicle registration)
	Voter Registration
	Financial Organizations (bank, credit cards, life insurance,retirement plan, etc.)
	Medical Organizations (medical plan, dental, physician, etc.)
	Membership Organizations (clubs and associations)

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Name Changes print this form

NOTICE OF NAME CHANGE
(For use with Medical Plans)

EMPLOYER / PLAN INFORMATION

Employer _______________________________ Date of Hire ______________

Plan Group Name _____________________________ Group # ____________

MEMBER INFORMATION

ID # ________________________ Date of Birth _______________

Current name on record ___________________________________

Address ______________________________________________

City _____________________ State ________ Zip Code ________

Telephone # ______________________

Social Security # ___________________ Male / Female (circle one)

Please change the current name on record to reflect the new married name.

New Name ______________________________________________

Address ______________________________________________

City _____________________ State ________ Zip Code________

(Check if applies)

___ The above reflects a new change of address.

I authorize you to make the above referenced record change. If you require additional forms to be filled-out please forward them to the address above. If you have any further questions regarding this matter please call me at

___________________.

(Phone Number)

_____________________ ___________ _____________________

(Sign name here) (Date) (Print name here)

Enclosure: Photocopied Certificate of Marriage