Request a change or correction to an individual's name or information.
Please send me an email when this change is completed
Name of group or individual on billing invoice:
Client ID:
Example: 123456-0 or 91010-150 as shown on your invoice
Please let us know the name of the member who needs an item corrected. Please enter it as it is currently shown on our records.
Information to be Corrected
Please Select
Member Name
Member Birth Date
Dependent Name
Dependent Birth Date
Member ID
Other-Use Memo Below
Please let us know the correct Information to use
Memo
Would you like a new wallet card sent?
Not Necessary
Yes, mail to member address
Yes, mail to group address