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Highmark Enrollment Form

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ENROLLMENT / WAIVER FORM

COMPLETE THIS APPLICATION IN ITS ENTIRETY IN BLUE OR BLACK INK. DO NOT USE PENCIL OR HIGHLIGHTER.

I. EMPLOYEE INFORMATION (Must be completed for both enrollees and waivers)

Effective Date

Employer Name

Group Number

Last Name

First Name

MI

Social Security No.

Address

Email Address

City

State

Zip

Home Phone

Work Phone

Employment Status

Date of Full-Time Hire

Hours Worked Per Week

COBRA Start Date

COBRA End Date

Marital Status (Please check one)

Gender

II. ENROLLMENT INFORMATION AND COVERAGE SELECTION

Covered Dependents and Relationship First Name & Middle Initial Social Security # Birthdate Sex Height Weight
Self
Spouse
Dom. Part.
Child
Other

*If “domestic partner” or “other” applies, complete using one of the following codes: (02) Adopted Child, (05) Grandchild, (07) Nephew or Niece, (17) Stepson or Stepdaughter and (29) Domestic Partner.

III. WAIVER OF COVERAGE

I HEREBY DECLINE MEDICAL COVERAGE

REASON FOR DECLINING MEDICAL COVERAGE

I HEREBY DECLINE VISION COVERAGE

COBRA REASON

Date of Event

I hereby certify that I have been given the opportunity to participate in the group insurance plan provided by my employer. If I and/or any of my Eligible Dependents desire to apply for this insurance at a later date, I may be required to wait until my group’s renewal or until a qualifying event occurs before coverage will be offered.

Employee Signature

Date

Employer Signature

Date

IV. ABOUT YOUR OTHER GROUP OR NON-GROUP HEALTH INSURANCE COVERAGE AND MEDICARE

Name of Insurance Carrier

Group Number

Effective Date

Name of Policy Holder

Policy Holder Date of Birth

Relationship to Policyholder

Policy Number

Policyholder Employment Status

Medicare Coverage (Please list any family member that is eligible for Medicare Benefits)

Dependent Health Insurance Claim Number Effective Dates Check Reason
Hospital (Part A) Medical (Part B) Prescription (Part D) Age Disability End Stage Renal Disease Medicare Supplement/Complement?

V. IMPORTANT: EMPLOYEE AND EMPLOYER MUST SIGN BELOW

I understand that this form enrolls those eligible persons listed above in the Products as described in the agreement between the plan and my employer. I authorize any payroll deductions required for the coverage and recognize that I must formally enroll my dependents on this form or they will not be covered.

To the best of my knowledge and belief, the information provided on this application is true and correct.

Authorized Employer Signature

Print Company Name

Employee Signature

Print Employee’s Name

Date

VI. MEDICAL HISTORY INFORMATION

Please answer each question below as completely as possible. Medical information disclosed in this section will not be used to determine eligibility. Check all conditions that apply and provide explanations below.

1. Cancer, Leukemia, Tumor or Cyst

2. Heart Surgery, Heart Disease, Pacemaker/Defibrillator, Irregular Heartbeat, Chest Pain, Heart Failure, Mitral Valve Prolapse

3. Vasculitis or Peripheral Vascular Disease

4. High Blood Pressure and/or High Cholesterol

5. Emphysema, COPD, Cystic Fibrosis, Asthma or Allergies

6. Sleep Apnea or Disease of the Throat, Ears, Nose, Sinuses or Eyes

7. Ulcerative Colitis, Crohn’s, Diverticulitis, Stomach Ulcers, Acid Reflux, GERD, Hernia, Gallbladder or Rectal Disorders

8. Diabetes Type I or II

9. Thyroid, Pituitary, Pancreas or Glandular Disorders or Growth Hormones

10. Hepatitis (A, B, C, or Autoimmune)

11. Bladder, Kidney, Prostate, Uterine, Dialysis, Abnormal PAP or Breast Condition

12. Pregnant? Due Date and complications

13. Arthritis, Joint Replacement, Joint Pain, Lupus, Fibromyalgia, Fractures or Limb Loss

14. Neck or Back Pain, Spine or Disc Disorders

15. Head or Spinal Injuries, Muscular Dystrophy, Cerebral Palsy, or Multiple Sclerosis

16. Blood Disorder such as Anemia or Hemophilia

17. Aneurysm, Blood Clot, TIA or Stroke

18. AIDS, HIV, Chronic Fatigue Syndrome, any Immune Suppressed Illness

19. Depression, Anxiety, ADD, ADHD, Psychotic Disorder

20. Any Drug or Alcohol Problems

21. Any Stem Cell or Organ Transplant

22. Cigarette or Tobacco use?

23. Any hospitalizations in the last 5 years

24. Any future surgeries discussed, planned or recommended

25. Currently taking any prescription medications?

26. Any other medical conditions not listed above?

27. Treated in the last five years for Macular Degeneration, Retinitis Pigmentosa, or Retinopathy?

VII. EXPLANATION SECTION

Provide an explanation for each box marked in questions 1 - 27. If additional space is needed, attach additional sheets.

Question number Patient Name Diagnosis Date Diagnosed Type of Treatment Medications From To Is ongoing treatment required? Date of most recent inpatient stay

I acknowledge and agree that any personally identifiable health information about me or my enrolled dependents is protected by HIPAA and other privacy laws. I further acknowledge and agree that Highmark may disclose enrollment, disenrollment, summary health and/or premium billing information as described in its Notice of Privacy Practices.

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing materially false information commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

VIII. IMPORTANT: EMPLOYEE/APPLICANT SIGNATURE (REQUIRED)

Employee Signature

Print Employee Name

Date

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What the Highmark Enrollment Form Is and why it matters

The Highmark Enrollment Form is the standard enrollment document used to enroll individuals, dependents, and employees in Highmark health insurance plans. It captures personal identifiers (legal name, date of birth, Social Security number or TIN), contact details, dependent information, selected plan or tier, effective dates, premium payment method, and attestations or certifications required by the insurer. Employers, brokers, and individuals use the form to establish coverage and verify eligibility; electronic completion and signature are routine where permitted under ESIGN and applicable state law.

Why accurate completion of the Highmark Enrollment Form matters

A correctly completed enrollment form establishes coverage, confirms eligibility, and reduces processing delays or payment errors. Proper data and signatures protect parties from coverage lapses and possible tax or compliance consequences while ensuring HIPAA-protected information is handled according to privacy rules.

Why accurate completion of the Highmark Enrollment Form matters

Who typically completes and signs this form

Verify that the signer has authority (employee, employer representative, or authorized agent) and confirm identity documentation where required.

  • Employees completing benefit elections for themselves and eligible dependents during onboarding or open enrollment.
  • Human resources or benefits administrators completing employer-submitted group enrollment packages.
  • Licensed brokers or agents completing enrollment with client authorization.

Core sections included in a professional Highmark Enrollment Form

A complete enrollment form organizes data for eligibility verification, premium calculation, coverage selection, and compliance. Clear grouping reduces back-and-forth with the insurer and speeds acceptance.

Member Details

Legal full name, date of birth, and Social Security number or TIN used for identity and tax reporting; inaccuracies can trigger backup withholding or delays.

Contact Information

Street address, city, state, ZIP, phone, and email used for plan notices, ID cards, and provider network communications.

Dependent Information

Names, birthdates, and relationship for each dependent; supporting documents may be required for newborns, spouses, or domestic partners.

Plan Selection

Plan name, coverage tier, and optional riders; include coverage start date and any election of cost-sharing or HSA options.

Payment and Employer Section

Premium payment method, employer contribution details, and payroll deduction authorization where applicable.

Attestation & Signature

Signed certification of accuracy, consent to enroll, and signature block for the member, employer representative, or authorized agent with date.

Step-by-step: completing the Highmark Enrollment Form

Follow these sequential steps to prepare and submit a complete enrollment packet with supporting documents and signatures.

  • 01
    Collect documents: Gather IDs, SSN/TIN, dependent proof, and employer authorization.
  • 02
    Fill fields: Enter legal names, dates, addresses, and plan choices per the fillable guide.
  • 03
    Review: Confirm accuracy with the member and employer representative.
  • 04
    Sign and submit: Apply required signatures and forward to Highmark or broker by the chosen channel.

Configuring an online completion workflow

When digitizing the form, set clear field rules and authentication to match compliance needs and reduce manual reviews.

Field Configuration
Authentication Email link or SMS code; stronger methods for agent submissions
Document format Use PDF or DOCX to preserve layout and form fields
Auto-reminders Enable scheduled reminders for unsigned forms
Templates Create employer-specific templates to prefill recurring fields

Technical considerations for eSubmission and eSignature

Ensure the chosen system can produce tamper-evident signed copies, preserve an audit trail, and meet any required compliance frameworks.

  • File formats: PDF, DOCX, and fillable PDF supported
  • Integrations: Connect to HRIS and CRM systems
  • Authentication: Email, SMS, or advanced verification

Where to send completed Highmark Enrollment Forms

Typical submission flows depend on whether enrollment is individual, employer-submitted, or broker-assisted; choose the route required by your plan.

  • Employer portal: Upload grouped employee enrollments through authorized employer site
  • Broker submission: Broker uploads via agent portal or transmits to Highmark
  • Member mail/email: Individual enrollments follow insurer instructions for secure upload or mail
  • Carrier intake: Highmark processes received packets and issues ID cards

Key timing and deadline considerations

Be aware of enrollment windows, employer deadlines, and effective-date rules to ensure continuous coverage and correct premium application.

Annual open enrollment:

Occurs once per plan year; exact dates vary by plan and employer

New-hire enrollment period:

Typically requires submission within the employer-specified new-hire window

Qualifying life events:

Special enrollment rights apply for marriage, birth, loss of other coverage

Coverage effective date:

Carrier applies start date per plan rules after receipt and acceptance

Retroactive corrections:

Corrections after submission may have limited retroactive effect

Common preparation mistakes to avoid

  • Submitting forms with mismatched names or initials causes identity verification delays and additional documentation requests.
  • Omitting SSN/TIN or entering it incorrectly can trigger backup withholding or prevent enrollment acceptance.
  • Leaving signature or date fields blank results in rejection and return-to-sender cycles that delay coverage.
  • Selecting the wrong plan code or tier often produces premium misbilling and requires manual correction with employer and carrier.

Risks and penalties from incorrect or late enrollment

Premium errors: May cause underpayment or billing disputes
Coverage gaps: Late submission can delay effective coverage
Tax consequences: Incorrect TIN may trigger 24% backup withholding
HIPAA exposure: Improper handling of PHI risks enforcement
Contractual breach: False attestations can have legal consequences
Administrative fines: Noncompliance may incur carrier or regulatory penalties

Essential data elements to collect securely

Member Name: Legal full name
Date of Birth: MM/DD/YYYY
SSN / TIN: Full SSN/TIN
Address: Street, city, state, ZIP
Plan Selection: Plan name or code
Signature: Signed and dated

eSignature vendor comparison for enrolling and signing forms

Basic pricing and feature differences among common eSignature providers for form completion and bulk enrollment workflows; signNow is listed first per platform comparison standards.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial Trial available Trial available Trial available Trial available
Bulk Send Yes (Business Premium) Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No
Envelope Cap No cap 100 envelopes/user/yr Varies by plan Varies by plan Varies by plan

Practical tips to speed acceptance and reduce errors

Follow these best practices to streamline processing and avoid common administrative delays when submitting a Highmark Enrollment Form.

Use validated templates and presets
Create employer- or broker-specific templates that prefill static fields (employer ID, payroll codes) and reduce manual entry errors across multiple enrollments.
Require signer verification
Enable at least email verification and consider SMS or knowledge-based authentication for agent-submitted forms to ensure attribution and reduce fraud risk.
Attach required proofs
Include scans of dependent documentation, marriage certificates, or birth certificates with the initial submission to prevent later requests and processing delays.
Preserve an audit trail
Store signed PDFs with certificate-of-completion metadata (IP, timestamp, signer email) so you can reproduce the record for audits or disputes.

Frequently asked questions about the Highmark Enrollment Form

Answers to common questions about electronic signing, correcting errors, and supporting documentation for enrollment.


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