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Enrollment or Change Form CHINA HMO and PPO Dental Plans 3217088 New Member Reinstatement Coverage Change Name Change Effective Date (AFPA USE ONLY) Name Last First M.I. Address Date of Birth Social

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What is enrollment or change form?

Enrollment or change form is a document used to enroll in or make changes to a specific program, service, or plan.

Who is required to file enrollment or change form?

Individuals or entities who wish to enroll in a program or service or make changes to their existing enrollment are required to file an enrollment or change form.

How to fill out enrollment or change form?

To fill out an enrollment or change form, individuals or entities need to provide accurate and up-to-date information as requested on the form. They must follow the instructions provided and submit the form by the designated deadline.

What is the purpose of enrollment or change form?

The purpose of an enrollment or change form is to collect necessary information for enrolling in a program or service, or for making changes to existing enrollment. It helps ensure that the correct information is recorded and processed accordingly.

What information must be reported on enrollment or change form?

Information required on an enrollment or change form may include personal or business details, contact information, program preferences, and any changes being made to existing enrollment.

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