This form is used to enroll or terminate a cardholder or dependent from a plan. It can also be used to update existing information. The form should be printed, filled out and then faxed or mailed to EHIM. EHIM's fax number is 248-948-9904.
If you want to include any additional information or instructions, feel free to attach a note to the form. A customer service representative will get back to you if any aspect of your form requires clarification.
This form is used to enroll or terminate a cardholder or dependent from a plan. It can also be used to update existing information. The form should be printed, filled out and then faxed or mailed to EHIM. EHIM's fax number is 248-948-9904.
If you want to include any additional information or instructions, feel free to attach a note to the form. A customer service representative will get back to you if any aspect of your form requires clarification.
EHIM