Membership Cancellation FormMaryland, District of Columbia and Northern Virginia Individual Plans
Mailroom Administrator P.O. Box 14651, Lexington, KY 40512Fax: 800-305-1351
CareFirst of Maryland, Inc. 10455 Mill Run Circle, Owings Mills, MD 21117
Group Hospitalization and Medical Services, Inc. CareFirst BlueChoice, Inc.
840 First Street, NE, Washington, DC 20065
This is not an application for insurance
If you originally bought insurance directly through the Maryland, District of Columbia or Virginia Exchange, then you must make changes through that same Exchange.
Name of Plan to Cancel:
Subscribers Last Name Subscribers First Name M.I.
Residence Address (Street) (City and State) (Zip Code)
Residence County Phone Number
( )Subscriber Group Number (of plan being cancelled) Subscriber Member Number (of plan being cancelled)
Requested Date to Cancel Plan (mm/dd/xxxx)
/ /
Reason for Cancellation of Plan
Where can I find my Member Number and Group Number?
1 Member ID this is the number providers will ask for to verify your coverage
2 Group # identifies your plan
Member NameJOHN DOEMember IDABC000000000
2.0 OPEN ACCESSHealthyBlue PlatinumPCP NameSmith, Jane
Group99K1
RxBIN 004336 RxPCN ADV RxGrp RX7546BCBS Plan 080/580
CopayD0 P0 S30 ER200 RX AV
CareFirst BlueChoice, Inc.
1
2
We need 710 business days to complete your request and will follow-up with you by letter to confirm this request. If you need assistance please call the Member Services telephone number on the back of your member ID card. Our service hours are MondayFriday from 8:00 am6:00 pm. So that we may serve you as quickly as possible, please have your ID card available.
REQUIRED SIGNATURE AND DATESubscribers Signature Date (mm/dd/xxxx)
/ /
CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are both independent licensees of the Blue Cross and Blue Shield Association.
Registered trademark of the Blue Cross and Blue Shield Association. Registered trademark of CareFirst of Maryland, Inc.
CUT9486-IN (11/14)
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., First Care, Inc. and The Dental Network are independent licensees of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association.
Registered trademark of CareFirst of Maryland, Inc.
Notice of Nondiscrimination and Availability of Language Assistance Services
CareFirst BlueCross BlueShield, CareFirst BlueChoice, Inc. 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: o Qualified sign language interpreters o 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: o Qualified interpreters o 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. Civil Rights Coordinator, Corporate Office of Civil Rights Telephone Number 410-528-7820
Mailing Address P.O. Box 8894 Baltimore, Maryland 21224
Fax Number 410-505-2011
Email Address [email protected] You can file a grievance by mail, fax or email. If you need help filing a grievance, our CareFirst Civil Rights Coordinator is available to help you. 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.
mailto:[email protected]://ocrportal.hhs.gov/ocr/portal/lobby.jsfhttp://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., First Care, Inc. and The Dental Network are independent licensees of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association.
Registered trademark of CareFirst of Maryland, Inc.
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.
(Amharic) -
855-258-6518 0
d Yorb (Yoruba) ttlko: kys y n wfn npa i adjtf r. le n wn dt pt o s le n lti
gb gbs n wn j gbdke kan. O ni t lti gba wfn y ti rnlw n d r lf. wn m-gb
gbd pe nmb fn t w lyn kd dnim wn. wn mrn le pe 855-258-6518 k o s dr npas jrr
tt a fi s fn lti t 0. Ngbt aoj kan b dhn, s d t o f a s so p m gbuf kan.
Ting Vit (Vietnamese) Ch : Thng bo ny cha thng tin v phm vi bo him ca qu v. Thng bo c th
cha nhng ngy quan trng v qu v cn hnh ng trc mt s thi hn nht nh. Qu v c quyn nhn
c thng tin ny v h tr bng ngn ng ca qu v hon ton min ph. Cc thnh vin nn gi s in thoi
mt sau ca th nhn dng. Tt c nhng ngi khc c th gi s 855-258-6518 v ch ht cuc i thoi cho
n khi c nhc nhn phm 0. Khi mt tng i vin tr li, hy nu r ngn ng qu v cn v qu v s c
kt ni vi mt thng dch vin.
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.
Espaol (Spanish) Atencin: Este aviso contiene informacin sobre su cobertura de seguro. Es posible que
incluya fechas clave y que usted tenga que realizar alguna accin antes de ciertas fechas lmite. Usted tiene
derecho a obtener esta informacin y asistencia en su idioma sin ningn costo. Los asegurados deben llamar al
nmero de telfono que se encuentra al reverso de su tarjeta de identificacin. Todos los dems pueden llamar al
855-258-6518 y esperar la grabacin hasta que se les indique que deben presionar 0. Cuando un agente de seguros
responda, indique el idioma que necesita y se le comunicar con un intrprete.
(Russian) !
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855-258-6518 , 0.
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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 of Maryland, Inc., Group Hospitalization and Medical Services, Inc., CareFirst BlueChoice, Inc., First Care, Inc. and The Dental Network are independent licensees of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association.
Registered trademark of CareFirst of Maryland, Inc.
(Hindi) : - 855-258-6518 0 ,
s-w (Bassa) To uu Cao! B nia k a ny e ke m gbo kpa o ni fu a-fa-tiin ny je dyi. B nia k
ee we j e m ke wa m m ke nyu nyu hw we ea ke zi. m ni kpe m ke b nia k ke gbo-
kpa-kpa m m dye e ni ii-wuu mu m ke se wii o p. Kpoo ny e m a fn-na nia e waa
I.D. kaa ein ny. Ny t sein m a na nia k: 855-258-6518, ke m m fo tee wa ke m gbo c m ke
na ma 0 k dyi paain hw. ju ke ny o dyi m g juin, po wuu m m po dyi, ke ny o mu o niin
ke ni wuu mu za.
(Bengali) : 855-258-6518 0
