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Web enrollee’s or dependent’s name, social security number, date of birth, name and number of the new pcp and the name and number of the new ipa. Web this document will explain the appropriate means to submit a tax id or legal name change request to blue cross and blue shield of north carolina. 22nd street, lombard, illinois 60148. Blue cross and blue shield of. Download (fillable pdf) group change request. Web employee change form return completed forms by: _____ complete this form and give to your benefits administrator, or mail to: Web forms and documents for individuals and families. Web enrollment and change form. Use a black or blue ballpoint pen only.
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