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HB2557

2016-17 Enrollment Materials

Forms

Mid-Year Change Form - Use this form to request changes to your enrollments if you experience a Qualified Status Change event outside the Open Enrollment Period

ACH Debit Authorization Form - Use this form to authorize payment if you are newly enrolling in coverage, or if you wish to change your bank account during the plan year.

Note: If you are continuing coverage from 2015-16 and wish to continue using the same bank account, you do not need to submit another ACH Debit Authorization Form. Your previous authorization will automatically continue.

HB2557 Frequently Asked Questions

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