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Pilgrim enrollment form REASON FOR SUBMISSION Please check all that apply The Harvard Pilgrim HMO Enrollment/Change Form PO BOX 9185 QUINCY MA 02269 1-888-333-HPHC www. Penalties may include imprisonment fines or a denial of insurance benefits. THE EMPLOYEE SPOUSE AND ALL DEPENDENTS AGE 18 YEARS AND OVER MUST SIGN THIS FORM FOR ENROLLMENT. EMPLOYEE SIGNATURE SPOUSE SIGNATURE if applicable 10/01 001-11 HPG DATE DEPENDENT SIGNATURE age 18 years - over WHITE - HARVARD PILGRIM COPY YELLOW - EMPLOYER COPY PINK - EMPLOYEE COPY. harvardpilgrim*org CONTRACT / ID NUMBER ENROLLMENT LOSS OF INSURANCE NEW HIRE ATTACH DOCUMENTS ANNUAL OPEN ENROLLMENT COBRA P/T TO F/T DATE CHANGE NAME/ADDRESS CHANGE CHANGE COVERAGE TYPE ADD DEPENDENT LISTED BELOW TERMINATE DEPENDENT LISTED BELOW TERMINATION NO LONGER ELIGIBLE LEFT EMPLOYMENT VOLUNTARY CANCELLATION DECEASED DATE MOVED FROM SERVICE AREA MARRIAGE DATE OTHER GROUP / COMPANY NAME DATE OF HIRE DIVISION EFFECTIVE DATE H P EMPLOYEE NAME FIRST ADDRESS MIDDLE APT. NO. STREET EMPLOYEE 02 SPOUSE LAST IF NOT SAME AS EMPLOYEE 04 UNMARRIED STEPCHILD UNDER 19 06 HANDICAPPED VERIFICATION REQUIRED 07 EX-SPOUSE IT IS VERY IMPORTANT THAT EACH MEMBER SELECT A PRIMARY CARE PHYSICIAN* AS A PLAN MEMBER YOU MUST CHOOSE A PRIMARY CARE PHYSICIAN PCP. IF YOU DO NOT HAVE A PCP NON-EMERGENCY AND MOST SPECIALITY CARE MAY NOT BE COVERED. LANGUAGE CODE 03 UNMARRIED CHILD UNDER 19 05 UNMARRIED FULL-TIME STUDENT OVER AGE19 STATE ZIP TELEPHONE WORK MARITAL STATUS PLEASE USE THE CODES LISTED BELOW TO COMPLETE DEPENDENT RELATION BLOCK PO BOX COUNTY CITY TELEPHONE HOME TYPE OF COVERAGE INDIVIDUAL 2-PERSON Only where offered FAMILY LAST MO DATE OF BIRTH DAY YR RELATION SEX SELECT A PRIMARY CARE PHYSICIAN AND TOWN FOR EACH MEMBER SOCIAL SECURITY NUMBER O1 ARE YOU A REGULAR PATIENT OF THIS DOCTOR Y N F M PCP DEPENDENT AS CA CV EN FR HA HM IT KH LO MN PT RU SP VI American Sign Language Optional WHAT LANGUAGE DO YOU SPEAK MOST OFTEN PLEASE LIST THE APPROPRIATE CODE AFTER EACH MEMBER S NAME* THIS INFORMATION WILL HELP US WORK TOWARD BEST MEETING YOUR NEEDS* Cantonese Cape Verdean English French Haitian Hmong Italian Khmer Laotian Mandarin Portuguese Russian Spanish Vietnamese IF YOU HAVE LISTED A FULL-TIME STUDENT S OVER AGE 19 BUT UNDER THE MAXIMUM STUDENT AGE SUPPLY THE FOLLOWING INFORMATION STUDENT S NAME NAME OF SCHOOL S Specify HAVE YOU EVER BEEN A MEMBER OF Pilgrim Health Care Harvard Community Health Plan HCHP OF NE HPHC OR HPHC OF NE YES NO IF YOU WOULD LIKE TO RECEIVE A MENU OF ELECTRONIC WAYS TO INTERACT WITH US LIST YOUR E-MAIL ADDRESS HERE* E-MAIL ADDRESS OPTIONAL THE E-MAIL MENU YOU RECEIVE MAY INCLUDE CHOICES SUCH AS SECURE E-MAIL WITH YOUR PHYSICIAN REPLACEMENT OF HPHC MAILINGS WITH E-MAILS POINTING TO OUR WEB-SITES HEALTH-RELATED UPDATES AND REMINDERS AND OTHER POSSIBLE OPTIONS* CONFIDENTIAL E-MAIL WILL BE SENT THROUGH A SECURE WEB-SITE AND YOU WILL RECEIVE NOTIFICATION THAT THERE IS A MESSAGE FOR YOU AT THE SITE* NON-CONFIDENTIAL UPDATES AND REMINDERS YOU ELECT TO RECEIVE WILL BE SENT DIRECTLY TO THE E-MAIL ADDRESS LISTED ABOVE* THIS INFORMATION MAY BE USED TO VERIFY ELIGIBILITY YOUR E-MAIL ADDRESS WILL BE STORED IN A PROTECTED DATABASE AND WILL REMAIN CONFIDENTIAL* I UNDERSTAND THAT MEMBERSHIP WILL BECOME EFFECTIVE UPON ACCEPTANCE BY THE PLAN AND THAT BENEFITS UNDER THE PLAN WILL BE EXPLAINED IN A SEPARATE DOCUMENT.

White earth enrollment applica... White Earth Reservation Tribal Council Application for Enrollment Tribal Enrollments/Vital Statistics P.O. Box 506 White Earth, Minnesota 56591 APPLICANT: Name: (First) (Middle) (Maiden) (Last) DOB:

Kaiser senior advantage disenr... SENIOR ADVANTAGE DISENROLLMENT FORM This form is to be completed for each member of your family who wishes to discontinue membership in the Kaiser Permanente Senior Advantage program. If you join

Enrollment form independent he... Enrollment Application/Change Form P.O. Box 710, Buffalo, NY 14231-0710 independenthealth.com Benefit Administrator Initials Today s Date MM / D D / Y Y Y Y 1. Employer Information/Plan Selection

United healthcare medicare enr... 2012 Individual Enrollment Form When you are ready to enroll Contact your local sales agent to help you choose the best plan for you and complete this individual enrollment form, or Call a UnitedHealthcare

Unicare eft enrollment form ERA Enrollment Form Please Fax or E-mail completed forms to: Fax: (804) 354-2529 / edi.ent.enroll Unicare.com EDI Technical Support: (877) 210-4083 Incomplete or illegible enrollment packages will

Premera enrollment form Other Coverage Questionnaire Enrollment Customer Service: 800-722-1471 Hearing Impaired: 800-842-5357 P.O. Box 91059 Seattle, WA 98111 Dear Subscriber: We appreciate your assistance in providing information

How to fill out a new york mem... New York Member Enrollment Form OHP MAILING ADDRESS: P. O. Box 7085, Bridgeport CT 06601 1-800-444-6222 www.oxfordhealth.com THANK YOU FOR CHOOSING AN OXFORD PRODUCT FOR YOU AND YOUR FAMILY. IMPORTANT:

Health net disenrollment form Contact us to verify your disenrollment before you seek medical services outside of Health Net Medicare Program s network. Health Net Medicare Programs employer group Disenrollment Form I f you request disenrollment you must continue to get all medical care from Health Net Medicare Programs until the effective date of disenrollment. Miss. Ms. Home Phone Number Please carefully read and complete the following information before signing and dating this disenrollment form If I have enrolled in another Medicare Advantage or Medicare Prescription Drug Plan I understand Medicare will cancel my current membership in Health Net Medicare Programs on the effective date of that new enrollment. We will notify you of your effective date after we get this form from you. Please fax this form to Health Net Medicare Programs Enrollment Services 818 337-7241 or mail to Last name First Name Medicare Birth Date Sex M Middle Initial F Mr. I understand that I might not be able to enroll in another plan at this time. I also understand that if I am disenrolling from my Medicare prescription drug coverage and want Medicare prescription drug coverage in the future I may have to pay a higher premium for this coverage. Your Signature Date Or the signature of the person authorized to act on your behalf under the laws of the State where you live. If signed by an authorized individual as described above this signature certifies that 1 this person is authorized under State law to complete this disenrollment and 2 documentation of this authority is available upon request If you are the authorized representative you must provide the following information Name Address Phone Number - Relationship to Enrollee 6021756 CA66520 8/10 Material ID H0562EG20110043 Compliance Approved 09142010. I understand that I might not be able to enroll in another plan at this time. I also understand that if I am disenrolling from my Medicare prescription drug coverage and want Medicare prescription drug coverage in the future I may have to pay a higher premium for this coverage. Your Signature Date Or the signature of the person authorized to act on your behalf under the laws of the State where you live. Your Signature Date Or the signature of the person authorized to act on your behalf under the laws of the State where you live. If signed by an authorized individual as described above this signature certifies that 1 this person is authorized under State law to complete this disenrollment and 2 documentation of this authority is available upon request If you are the authorized representative you must provide the following information Name Address Phone Number - Relationship to Enrollee 6021756 CA66520 8/10 Material ID H0562EG20110043 Compliance Approved 09142010. I understand that I might not be able to enroll in another plan at this time. I also understand that if I am disenrolling from my Medicare prescription drug coverage and want Medicare prescription drug coverage in the future I may have to pay a higher premium for this coverage. Your Signature Date Or the signature of the person authorized to act on your behalf under the laws of the State where you live. If signed by an authorized individual as described above this signature certifies that 1 this person is authorized under State law to complete this disenrollment and 2 documentation of this authority is available upon request If you are the authorized representative you must provide the following information Name Address Phone Number - Relationship to Enrollee 6021756 CA66520 8/10 Material ID H0562EG20110043 Compliance Approved 09142010.

Re enrollment form nyack colle... NYACK COLLEGE APPLICATION FOR RE-ENROLLMENT Name: (Please Print) Last First Middle Address: Street City State Zip Student ID #: Date of Birth: Telephone No.: ( E-mail Address: ) Last Term at Nyack:

Vsp enrollment form with depen... Enrollment Form with Dependent Data Name of group (employer): Employee last name, first name, middle initial: Social Security Number: Gender: Date of birth (month/date/year): male female employee

Vsp enrollment forms VSP Enrollment Form Wyoming Employees' Group Insurance New Enrollment Change Plan Options (Plan B or Plan C) Change Coverage (How many members on the plan) Vision Choice - Your election will be in

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