Fillable State Health Benefit Plan Open Enrollment (OE) Election Correction Form Employer must Fax to SHBP no later than December 31 st at 1-866-828-4796 - cobbk12

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GEORGIA DEPARTMENT OF COMMUNITY HEALTH State Health Benefit Plan Open Enrollment (OE) Election Correction Form Employer must Fax to SHBP no later than December 31 st at 1-866-828-4796 Please read the Terms, Conditions and Instructions on the back of this form prior to completing the form and submitting to your HR Department. I. Member Identification SSN Last Name - - Male Female Date of Birth /
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