Medicare Advantage Billing Change Request * Indicates a required field Are you the Member or an Authorized Representative? Please select one Member Authorized Representative To the authorized representative who is assisting with the attestation: You are attesting that you are authorized to act on behalf of the member. You also certify that: You are authorized under state law to complete this attestation. Documentation of this authority is available upon request by Blue Cross Blue Shield of Massachusetts or by Medicare. Authorized Representative Information Professional status or relationship e.g. child, attorney, etc. - Select -SpouseSon/DaughterAttorneyFriendOther Relationship to member Relationship to member - Other First Name Last Name Phone Number (optional) Email (optional) Street Address (optional) Apartment or Unit Number (optional) City (optional) - None -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State (optional) Zip Code (optional) Member Information First Name Last Name Phone Number (optional) Email (optional) Street Address Apartment or Unit Number (optional) City - Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Zip Code Enter a three-character prefix, then numerical digits Member ID Plan Billing Change Request Please select one Premium Withhold Direct Bill (pay directly to the plan) I choose to pay my premium by automatically having it withdrawn from one of the following options Social Security (SSA) Railroad Retirement Board (RRB) More You must continue to pay your plan premium until your Premium Withhold deductions begin. Member Attestation By submitting this attestation, I acknowledge that I have read and understand the contents of this declaration. To the best of my knowledge, the information on this attestation is true and correct. Authorized Representative Attestation By submitting this attestation, I, the authorized representative, acknowledge that I have read and understand the contents of this declaration. To the best of my knowledge, the information on this attestation is true and correct. Submit You will be contacted if additional information is needed. Pay My Bill Contact Information If you do have questions, call us at 1-800-200-4255 (TTY: 711). April 1 - September 30 8:00 a.m. - 8:00 p.m. ET Monday - Friday October 1 - March 31 8:00 a.m. - 8:00 p.m. ET Seven days a week