CARE Insurance Change Request Form

CARE Insurance Change Request Form

This form is to be utilized ONLY if:

You have applied and been approved for a 2020 CARE Grant
You now have a change in your insurance and wish to request a change in your 2020 grant funding

CARE funding for any grant calendar year requires grantees to notify the NGCF as soon as any changes in insurance occur. Failure to notify the NGCF of any changes in insurance may lead to grant termination.

Unique Patient ID (UPI# on your grant notification letter mailed with your first grant check)

Patient Name

Primary Insurance Information

Date change will occur

Attach Proof of Insurance/Verification of Change

Secondary Insurance Information

Date change will occur

Attach Proof of Insurance/Verification of Change

Pharmacy Insurance Information

Date change will occur

Attach Proof of Insurance/Verification of Change

Dental Insurance Information

Date change will occur

Attach Proof of Insurance/Verification of Change

Vision Insurance Information

Date change will occur

Attach Proof of Insurance/Verification of Change

Other Insurance Information

Date change will occur

Attach Proof of Insurance/Verification of Change

You are required to submit Proof of Insurance with this request.

Proof of Insurance is:

A copy of your notification regarding your NEW insurance premium cost which includes the initiation date of coverage.

OR

A copy of your most current invoice for the NEW insurance indicating the premium cost & initiation of coverage date

OR

A copy of your most current paycheck indicating the cost of your NEW insurance (if insurance is provided through employer)

OR

A copy of your most current bank statement showing the NEW insurance payment for each insurance policy for which the NGCF pays the premium payable to you or your family member (medical, dental, vision)

It is your responsibility to ensure the proof of insurance you are providing accurately reflects the 2020 premium for each policy.

Contact Information