Standard Form 2810 Notice of Change in Health Benefits Enrollment

This section includes instructions and definitions of the fields on SF 2810.

The following fields are available on the Standard Form 2810, Notice of Change in Health Benefits Enrollment form:

Address Line - Enrollee

Enter the enrollee's address.

Agency Address

Enter the Agency address.

Agency Address Line 2

Enter the second line of the Agency address, if applicable.

Authorizing Official First Name

Enter the authorizing official's first name.

Authorizing Official Last Name

Enter the authorizing official's last name.

Authorizing Official Middle Initial

Enter the middle initial of the authorizing official, if applicable.

Changed Address - Enrollee

Enter enrollee's new address line 2, if applicable.

Changed City 

Enter the enrollee's new city.

Changed First Name - Enrollee

Enter the enrollee's new first name.

Changed Last Name - Enrollee

Enter the enrollee's new last name.

Changed State

Select the enrollee's new State.

City - Service Provider

Enter the service provider's city.

Date

Enter the date of the action in MM/DD/YYYY format.
OR
Use the calendar icon to select the date.

Date of Birth

Enter the enrollee's date of birth in MM/DD/YYYY format.

Date of Death

Enter the enrollee's date of death in MM/DD/YYYY format.
OR
Use the calendar icon to select the date.

Date This Action Becomes Effective

Enter the date this action becomes effective MM/DD/YYYY format.
OR
Use the calendar icon to select the date.

Enrollment Code Number

Enter the enrollee's enrollment code number.

First Name - Enrollee

Enter of the enrollee's first name.

Home Mailing Address - Enrollee

Enter the enrollee's mailing address.

Last Name - Enrollee

Enter the enrollee's last name.

Middle Name - Enrollee

Enter the enrollee's middle initial, if applicable.

Name of Tribal Employer

Enter the name of tribal employer.

Part B Termination

Check the checkbox to terminate the SF 2810, if applicable. The default is an unchecked box, which does not terminate coverage.

Part D Reinstatement

Check the checkbox to reinstate the SF 2810, if applicable.

Payroll Office Number

Displays the payroll office number.

Personnel Contact First Name

Enter the personnel contact's first name.

Personnel Contact Last Name

Enter the personnel contact's last name.

Personnel Phone Number

Enter the personnel phone number in (xxx) xxx-xxxx format.

POI

Select the enrollee's POI.

Remarks

Enter any applicable remarks (e.g., Correction).

Service Provider - Contact

Displays the service provider.

Social Security Number 

Enter the enrollee's SSN.

State - Service Provider

Enter the service provider's State.

Telephone - Service Provider

Displays the service provider's telephone number in (xxx) xxx-xxxx format.

Tribe 

Select the available name of the tribe from the from the dropdown.

ZIP - Enrollee

Enter the enrollee's ZIP code.

ZIP - Service Provider

Enter the service provider's ZIP code.