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Form preview Electric vehicle residential r... Electric Vehicle Residential Rates Customer Enrollment Form Aloha, Thanks for your interest in Hawaiian Electric's Electric Vehicle Pilot Rates. To enroll, please fill out this form and return it,
Form preview Bcbs ga fillable eft enrollmen... Electronic Funds Transfer Enrollment Form Electronic Funds Transfer (EFT) Support Atlanta, North Georgia and South Georgia - Please contact your local Representative. Please FAX All Forms to: (404)
Form preview Disenrollment form TRICARE PRIME DISENROLLMENT REQUEST AGENCY DISCLOSURE NOTICE Form Approved OMB No. 0720-0008 Jul 31, 2013 The public reporting burden for this collection of information is estimated to average 5 minutes
Form preview Cigna enrollment change form c... Enrollment / Change Form Consolidated Employer Complete Section A A OPEN ENROLL. CHANGE NEW ENROLL. Insured and/or Administered by Connecticut General Life Insurance Company CIGNA HealthCare Please print and thank you for providing this information EFFECTIVE DATE OF ADD/CHANGE/ CANCELLATION MM/DD/CCYY EMPLOYER NAME EMPLOYER ADDRESS REINSTATE CIGNA ACCOUNT NO. EMPLOYEE S SIGNATURE / DATE 581336c SPOUSE S SIGNATURE / DATE DISTRIBUTION Original CIGN...
Form preview Direct deposit enrollment form... DIRECT DEPOSIT ENROLLMENT FORM. ***IMPORTANT- PLEASE READ AND SIGN ... PLEASE DEPOSIT FULL AMOUNT (OR) $ ROUTING / ABA # ...
Form preview Prescriber enrollment form lot... Prescribing Program for Prescriber Enrollment Form Prometheus will ensure that healthcare providers who prescribe are specially certified in the Prescribing Program for
Form preview Hip utah enrollment form a P P l i c at i o n g u i d e application Guide Please consider the following when choosing between HiPutah and federal-HiPutah: HiPutah traditional coverage options $500Deductible/$2,000Out-of-PocketMaximum
Form preview Edi enrollment form ask electr... EDI Enrollment Form Instructions Blue Cross and Blue Shield of Kansas ONLY Employer Group Information: Organization Name Mailing Address City, State, Zip Contact Name(s) Telephone # Fax # E-mail Address
Form preview Form inr PATIENT ENROLLMENT FORM FOR PT/INR AT HOME MONITORING SERVICE mdINR - 59 Windsor Hwy Suite 240 New Windsor NY 12553 Quality of Care. Quality of Life Patient Information PATIENT NAME Last Name First Middle Initial DATE OF BIRTH GENDER Male PATIENT MAILING ADDRESS Street Suite Apt and/or Floor HOME PHONE CITY Female EMAIL STATE ZIP CODE EMERGENCY CONTACT Last Name First Middle Initial No Is patient being treated for active infection Yes PHONE If yes please specify below Any known allergies RELATIONSHIP CELL PHONE ORDER TAKEN BY Last Name First Middle Initial TIME DATE Primary Secondary Insurance Information YOU MAY CHOOSE TO FILL IN THE INSURANCE SECTION - OR TO SAVE TIMEYOU MAY FAX A COPY OF BOTH SIDES OF THE PATIENT S INSURANCE CARD OR FAX A SYSTEM PRINT-OUT OF THE PATIENT S INSURANCE INFORMATION PRIMARY INSURANCE NAME OF INSURED if other than the above patient DATE OF BIRTH MAILING ADDRESS Street and or Suite GROUP NUMBER POLICY NUMBER PHONE NUMBER NAME OF EMPLOYER SECONDARY INSURANCE Customer Service Number 800-877-4910 Form 010v4 Enrollment Fax Number 877-222-6580 PHYSICIAN ORDER FORM Ordering Physician Information Patient Name EFFECTIVE DATE PROVIDER NPI PATIENT DATE OF BIRTH PRESCRIBING PHYSICIAN Last Name First Middle Initial PATIENT GENDER GROUP PRACTICE OR HOSPITAL NAME PHYSICIAN OFFICE CONTACT NAME Statement of Medical Necessity and Prescription This patient s condition requires long term anticoagulation therapy to stabilize INR values and reduce the risks associated with thromboembolism such as stroke heart attack and blood clot formation. It is medically necessary for this patient to test his/her INR values frequently to stabilize coagulation and avoid negative outcomes. Enrollment in mdINR s home PT/INR Monitoring Service enables the patient to self-test frequently thereby optimizing therapeutic range. I and my patient understand that results from self-testing will be reported to mdINR for the duration of the patient s anticoagulation therapy. I further certify this patient has been on therapy greater than 90 days and that this patient or his/her caregiver is fully capable of performing these tests reporting the results to mdINR and is able to make adjustments to anticoagulation therapy as directed by me in response to reported results. I understand that mdINR s PT/INR Monitoring Service is for weekly testing patients only. I also understand that all INR results that are 1. 4 and 5. 0 will be considered by mdINR to be Patient Panic Values and I will be notified when results are in this range. Fax Options Patients Diagnosis Atrial Fibrillation / Flutter - 427. 31 Fax Every Result Mechanical Heart Valve - V43. 3 Only Fax Out of Range Results Primary Hypercoagulable State 289. 81 Pulmonary Embolism - 415. 11-415. 19 BELOW ABOVE Fax Out of Range Monthly Summary DVT - 453. 40 NOTE Every result will be faxed unless otherwise specified above. Other Ven* Embolism/ Thrombosis Care Plan TO Target INR Range LOW HIGH mdINR Standard Phone Notification We will call your office for any results 1.
Form preview State health benefits program... Commonwealth of Virginia State Health Benefits Program Enrollment Form For Retirees, Survivors And LTD Participants InItIal EnROllMEnt DEaDlInES: New retirees or long-term disability participants
Form preview 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.
Form preview 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:
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