Provider notification of a deceased member

Providers may use this form to notify Asuris of the passing of one of our members. Completed forms are submitted to and processed by our Membership departments. Please provide the following information regarding your office and the member in question.

Please note: this form is intended for informational purposes only to allow Asuris to better manage and resolve our member's account. We strive to create a better experience by taking an active role in assisting those responsible for handling a deceased member's business, including the member's family and their providers. In most cases, official notifications must be received from the following sources before we are able to change our member's status:

Centers for Medicare and Medicaid Services (CMS) regarding Medicare or MedAdvantage members.
Employer groups when the member's employer provides their health care coverage and Asuris administers their plan.

Member information

First name*

Last name*

ID number*

Group number*

Date of birth*

Date of death*

Name of follow-up contact for deceased member*

Phone number of follow-up contact for deceased member*

Provider information

First name*

Last name*

Your position

Provider / office name*

Provider phone number*

Office email address*

National Provider Identifier (NPI)*

Tax ID*

Role in member's care*