- Check the box that indicates the reason for your change.
- Complete the Date of Event box.
- Only list the dependents that will be affected by this change.
- If adding a dependent(s) to a TVHP (HMO) or VHP plan, you must indicate a Primary Care Physician, ID number and existing patient status.
- If the dependent(s) is 19 or older, complete the student section and indicate the name of the school and its location, the student's begin date and anticipated graduation date.
- If you or your dependent(s) are covered by another health or dental plan, complete this section.
- Subscriber's signature and date.