Request and ID Card Form for TRS Employees

If you do not know your contract number, please contact the Health Plan.

Items in RED are required to process this form.

Subscriber's Contract Number: (first 9 digits of your id number on your medical card)
Subscriber's First Name:
Subscriber's Last Name:
Subscriber's Date of Birth:
Do you need a card for all members on the policy? If no, list information for all members (including self) who need a new ID card.	Yes No
Member's First Name:
Member's Last Name:
Member's date of birth:

Member's First Name:
Member's Last Name:
Member's date of birth:

Member's First Name:
Member's Last Name:
Member's date of birth:
Address/Phone
Street:
City:
State:
Zip:
Phone:

www.swhp.org