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 2021 CARE Grant
You now have a change in your insurance and wish to request a change in your 2021 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. Only enter the number, NOT the #.)

Patient Name

Primary Insurance Information

Date change will occur

Attach Proof of Insurance/Verification of Change (PDF only)

Secondary Insurance Information

Date change will occur

Attach Proof of Insurance/Verification of Change (PDF only)

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 (PDF only)

Vision Insurance Information

Date change will occur

Attach Proof of Insurance/Verification of Change (PDF only)

Other Insurance Information

Date change will occur

Attach Proof of Insurance/Verification of Change (PDF only)

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)

It is your responsibility to ensure the proof of insurance you are providing accurately reflects the 2021 premium for each policy.

Please use this space to share any specific notes the NGCF should be aware of when considering your request, i.e. the change in premium request is lower than indicate on your proof of insurance because your employer is covering the cost or a percentage of the cost for the employee.

Please note that it is possible for requests made to be denied due to request exceeding available CARE funds. This form in no way guarantees the approval of additional requested grant funds.

Contact Information