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Blue Choice

Individual Change Request Form

If you have a BlueChoice for Kids, BlueChoice for Young Adults or MyChoice Individual Health Coverage policy, you can use the Individual Change Request Form to:

  • Cancel your plan on the next due date
  • Change your address
  • Add/change your bank draft

Print and complete the form. Send the form to us using the instructions at the bottom.

If you have coverage through a group plan, contact your employer to make these changes.

Please note: Your policy will be cancelled at the end of the month in which you made the request.