Membership Change Instructions

On the Group Enrollment Form:


Section 1

  • Complete in full.

 Section 3

  • Check the box that indicates the reason for your change.
  • Complete the Date of Event box.

 Section 4

  • 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.

 Section 5

  • If you or your dependent(s) are covered by another health or dental plan, complete this section.

 Section 6

  • Subscriber's signature and date.