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ARKANSAS HEALTH INSURANCE MARKETPLACE 221 W 2nd, Suite 700 Little Rock, AR 72201 HP/SAD Data Change Request Form PY2017 Section 1 This document includes fillable form fields. If you complete electronically,

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How to fill out qhpsadp data change request

01

Obtain the qhpsadp data change request form from the HR department.

02

Read the instructions on the form carefully before filling it out.

03

Gather all the required information, such as employee ID, name, and the details of the requested data change.

04

Ensure the accuracy of the information provided.

05

Fill out the form by following the points mentioned below:

06

Write your personal information, including your full name, employee ID, and contact details.

07

Specify the type of change you are requesting, such as address change, marital status change, or dependent update.

08

Provide the necessary details for the requested change. For example, if you are changing your address, include the new address and effective date.

09

If applicable, provide supporting documents along with the form, such as marriage certificates or birth certificates for dependent updates.

10

Sign and date the form.

11

Submit the completed qhpsadp data change request form to the HR department.

12

Wait for confirmation from the HR department regarding the processing of your request.

13

Keep a copy of the filled-out form for your records.

Who needs qhpsadp data change request?

01

Employees who need to update or change their qhpsadp (Qualified High Deductible Health Plan with a Savings Account) data should submit a qhpsadp data change request.

02

This may include employees who have experienced a change in personal information, such as a change in address, marital status, or dependents.

03

Employees who want to update their beneficiary information or make any amendments to their qhpsadp data would also need to submit this request.

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What is qhpsadp data change request?

Qhpsadp data change request is a form used to request changes to data related to the QHP or SADP.

Who is required to file qhpsadp data change request?

Insurance companies offering Qualified Health Plans (QHP) or Stand-alone Dental Plans (SADP) are required to file qhpsadp data change request.

How to fill out qhpsadp data change request?

To fill out qhpsadp data change request, one must provide accurate information regarding the requested changes in the designated form.

What is the purpose of qhpsadp data change request?

The purpose of qhpsadp data change request is to ensure that the data related to QHP or SADP is up to date and accurate.

What information must be reported on qhpsadp data change request?

Information such as plan details, provider network changes, and any updates to covered services must be reported on qhpsadp data change request.

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