Notice of Additional Health Benefit Information

This form can be used to coordinate benefits between plans and make the most of your coverage. For example, if you, your spouse and/or dependents are covered under more than one plan, you have the opportunity to maximize your reimbursement of your health-related, out-of-pocket expenses for things like prescription drugs, dental care, eye glasses and more.

Complete this form in the event that your spouse or one of your dependents has gained their own health benefits coverage; your spouse or one of your dependents has lost their own health benefits coverage; your spouse or one of your dependents’ health benefits coverage changes; or if you, your spouse or dependent(s) has other benefits coverage (For example, adding to your coverage a step-child who also has coverage through each biological parent).

Note: The ASEBP covered member is the only person who is eligible to sign this form.

Keeping ASEBP updated with this information allows us to help you ensure you have accessed all possible sources of payment for your claims and that your claims can be paid as efficiently as possible.  If you have any questions about this form, please contact ASEBP.

The Change Application form is used to add or delete dependents (i.e. single to family coverage); advise ASEBP of any name changes; change address information, change beneficiaries or change benefit coverage.

Note: If you are currently employed by your school jurisdiction, please forward the Change Application form to your employer upon completion.