Enrollment additions and deletions

To ensure proper coverage and billing, please be sure to report enrollment changes such as new eligible employees, newborns, divorces and employee terminations to us immediately. Please use the Enrollment Change Form, available below, to submit new subscribers or delete employees who are no longer eligible or who leave your employment. Changes must be reported within 30 days.


Change of Status Form for address or name changes, adding a newborn, deleting dependents or terminating coverage for active subscribers.

New Hire / Enrollment Package to enroll employees in practices offering one MDA Health Plan option.

Waiver of Coverage Form to document that an employee opts to waive participation in your group health plan.