Scott & White Health Plan

ERS 2012 - Request ID Card

State of Texas and Higher Education
Employees, Retirees, and their Dependents

PY2012

Subscriber's Information

Subscriber's Contract Number: *

The first nine 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?: *

Yes

If no, list information for all members (including self) who need a new ID card.

Member Information

Member's First Name:

Member's Last Name:

Member's Date of Birth:

Member 2 Information

Member 2 First Name:

Member 2 Last Name:

Member 2 Date of Birth:

Member 3 Information

Member 3 First Name:

Member 3 Last Name:

Member 3 Date of Birth:

Contact Information

Street: *

City: *

State: *

ZIP: *

Phone: *

Please enter daytime phone with area code (XXX) XXX-XXXX.

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