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Scott & White Health Plan
Change of Address/Phone Request


Addresses will be changed for all members on the subscribers policy.
Address changes will only be reflected in the Scott & White Health Plan system.

Items in RED are required to process this form.
Subscriber Information
Subscriber's Contract Number:
(first 9 digits of your id number on your medical card)
First Name:
Last Name:
E-mail:
Previous Address/Phone
Street:
City:
State:
Zip:
Phone:
New Address/Phone
Street:
City:
State:
Zip:
Phone:
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