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P.O. Box 30192 Salt Lake City, UT 8413001928014425038/8005385038selecthealth.enrollment Form and Instructions Large Employer You must read all instructions before completing and signing the Enrollment

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How to fill out dependent address change form

01

Obtain the dependent address change form from the appropriate department or agency.

02

Fill out the form with accurate and up-to-date information about the dependent whose address is changing.

03

Provide any necessary supporting documentation, such as proof of address or identification.

04

Submit the completed form and supporting documentation to the designated office or individual for processing.

Who needs dependent address change form?

01

Any individual who has a dependent whose address is changing may need to fill out the dependent address change form.

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What is dependent address change form?

The dependent address change form is a document used to update the address of a dependent on file.

Who is required to file dependent address change form?

Any individual who has dependents listed on their record and their dependents' addresses have changed is required to file the dependent address change form.

How to fill out dependent address change form?

To fill out the dependent address change form, one must provide their personal information, the dependent's information, and the new address details.

What is the purpose of dependent address change form?

The purpose of the dependent address change form is to ensure that the correct address information is on file for dependents.

What information must be reported on dependent address change form?

The dependent's name, relationship to the individual, old address, and new address must be reported on the dependent address change form.

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