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Highmark enrollment form 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. I acknowledge and agree that any personally identifiable health information about me or my enrolled dependents Protected Health Information is protected by The Health Insurance Portability and Accountability Act of 1996 HIPAA and other privacy laws and that in accordance with those laws Highmark may use and disclose Protected Health Information for payment treatment and health care operations as described in its Notice of Privacy Practices. I understand that a copy of Highmark s Notice of Privacy Practices is available on Highmark s Web site or from the Highmark Privacy Office. I further acknowledge and Employee Signature Print agree that Highmark may disclose enrollment disenrollment summary health and/or premium billing information requested by the POR Producer of Record for purposes of inputting updating and/or reviewing the same for the above identified business. In addition as long as you are covered by the group s health insurance plan provided by your employer if you have a new dependent as a result of marriage birth adoption or placement for adoption you may be able to enroll yourself and your dependents provided that you request enrollment within 30 days after the marriage birth adoption or placement for adoption. BOTH EMPLOYEE AND EMPLOYER SIGNATURES ARE REQUIRED FOR WAIVERS Highmark Health Insurance Company is an independent licensee of the Blue Cross and Blue Shield Association ENR-129 R4-12 IV ABOUT YOUR OTHER GROUP OR NON GROUP HEALTH INSURANCE COVERAGE AND MEDICARE Other Group or Non-Group Health Insurance Coverage Name of Insurance Carrier Name of Policy Holder Policy Holder Date of Birth Relationship to Policyholder Policy Number Policyholder Employment Status q Retired - List Date of Retirement Medicare Coverage Please list any family member that is eligible for Medicare Bene ts Name of Subscriber or Dependent Check Reason For Medicare Coverage Health Insurance Claim Number Hospital Part A Medical Part B Prescription Part D Age Disability End Stage Renal Disease Medicare Supplement or Complement q Yes q No 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. ENROLLMENT/WAIVER FORM q ENROLLING q WAIVING COMPLETE THIS APPLICATION IN ITS ENTIRETY IN BLUE OR BLACK INK. DO NOT USE PENCIL OR HIGHLIGHTER* I. EMPLOYEE INFORMATION Effective Date Employer Name Last Name Must be completed for both enrollees and waivers Group Number First Name MI Payroll Location Social Security No* Marital Status Please check one Address Email Address City State Employment Status q Active q COBRA q Disabled Zip Date of Full-Time Hire Mo Day Yr Home Phone Hours Worked Per Week q Single/Widowed q Married q Divorced Work Phone COBRA REASON Start Date q Deceased q Involuntary Lay-Off Date of Event End Date q Left Employment q Other II ENROLLMENT INFORMATION AND COVERAGE SELECTION Covered Dependents and Relationship First Name Middle Initial show Last Name if different from Subscriber Birthdate / Self q Spouse q Dom* Part.

Net enrollment form Welcome to Health Net SIMPLE STEPS FOR COMPLETING THE FORM 1 Review the materials enclosed in your enrollment packet. You can use your copy of the Health Net enrollment form as your temporary ID card until you receive your permanent ID card. SMALL BUSINESS GROUP ENROLLMENT AND CHANGE FORM Medical and Life/AD D plans are provided by Health Net of California Inc. and/or Health Net Life Insurance Company together the Health Net Entities. You must request special enrollment within 30 days 6015436 11/07 Health Net is a registered service mark of Health Net Inc. All rights reserved. EMPLOYER NAME HEALTH NET ENROLLMENT AND CHANGE FORM FOR SMALL BUSINESS GROUP EFFECTIVE DATE EMPLOYER GROUP NUMBER Medical 4 DO YOU OR YOUR DEPENDENTS HAVE OTHER HEALTH CARE COVERAGE If yes please complete ths section including Medicare. Please contact the Health Net Customer Contact Center at the toll free numbers below should you need assistance in completing this form or if you have questions about your coverage English Cantonese Korean Mandarin Spanish Tagalog Vietnamese 1-800-361-3366 1-877-891-9050 1-877-339-8596 1-800-331-1777 If you have questions about your dental or vision coverage please call Dental 1-800-880-8113 Vision 1-866-392-6058 call your physician group directly or contact Health Net Provider Services at 1-800-641-7761. HMO HMO Silver Network Salud con Health Net HMO SELECT ELECT Open Access EPO Dental HMO Enrollees Participating Physician Group PPG Primary Care Physician PCP and Dental Provider Selection* Please note if you do not select a participating physician group Primary Care Physician or Dental Provider for yourself and each of your eligible dependents a physician group Primary Care Physician and Dental Provider will be selected for you. Emergency and Urgently Needed Care If your situation is life threatening or an emergency Call 911 or go to the nearest Hospital* medical care right away go to the nearest hospital or medical center. If you are outside your physician group s service area Go to the nearest hospital medical center or call 911. In all cases contact your Primary Care Physician or physician group as soon as possible to inform them about your condition* PPO FLEX NET Enrollees appropriate number within 48 hours of being admitted or as soon as possible. PRE-CERTIFICATION You the member are responsible for obtaining certification for certain services. Please check your plan certificate for a list of services requiring pre-certification* SBG2006EEFORM 2/06 For pre-certification please call 1-800-977-7282 Pre-existing Conditions and Creditable Coverage Your coverage under the PPO EPO and Flex Net benefit plans may be subject to pre-existing condition limitations for a maximum period of six months from the effective date of your enrollment. In accordance with state and federal law Health Net Life Insurance Company will credit any prior coverage that you document at the time you apply to enroll in PPO EPO or FLEX NET provided the prior coverage qualifies as creditable coverage as defined under federal and state law.

New york member enrollment for... New York Member Enrollment Form ? OHI MAILING ADDRESS: P. O. Box 29142, Hot Springs, AR 71903 ? 1-800-444-6222 ? www.oxfordhealth.com Thank you for choosing an Oxford product for you and your family.

Allstate enrollment form saras... AMERICAN HERITAGE LIFE INSURANCE COMPANY (AHL) 1776 AMERICAN HERITAGE LIFE DRIVE JACKSONVILLE, FLORIDA 32224 ENROLLMENT AND EVIDENCE OF INSURABILITY FORM c New Certificate c Change/Increase Certificate

Metlife member enrollment form... Metropolitan Life Insurance Company Enrollment Form for Group Insurance SBC Administration P.O. Box 14593, Lexington, KY 40512-4593 Employee Name (Last, First, Middle) Your Home Address City Your

Enrollment form for automatic... ENROLLMENT FORM FOR AUTOMATIC PAYMENTS Use this form to ensure continued automatic drafting of your payments. 750-2022-0713F - Open Enroll It s the easiest way to make sure your mortgage payments

State of nebraska substitute f... Clear Form STATE OF NEBRASKA SUBSTITUTE FORM W-9 & ACH ENROLLMENT FORM Return Form to the Requester. (Rev. October 2013) Requester Information: Agency: Name: Address: Phone: Fax: E-mail: Substitute

Dakotacare enrollment form ple... DakotaCare Enrollment Form This agreement must be completed and approved by DakotaCare prior to sending electronic claims through Secure EDI. Please complete the required information below. A DakotaCare

Enrollmentchange form delta de... ENROLLMENT/CHANGE FORM Delta Dental of Arkansas P.O. Box 15965 North Little Rock, AR 72231 E-mail: eligibility ddpar.com Fax (501) 992-1890 ? New Enrollment ? Status Change ? Address Change ? Termination

Circle of health mille lacs ba... Circle of Health Mille Lacs Band of Ojibwe Enrollment Form 43500 Migizi Dr. Onamia, MN 56359 (888) 622-4163 toll free (320) 532-4354 - fax Name: DOB: Last First Middle Enrollment #: 410B- SSN: - -

Generic 401k enrollment form Generic 401K Enroillment Form Generic 401 k Plan Enrollment/ Change Form Indicate Action New Enrollment Contribution Change Discontinue Contribution Employee Data Last Name First Name Middle Name Employee Number Social Security Number Address City State Zip Date of hire Date of birth Marital Status Single Married I wish to contribute 0.

Kaiser permanente cobra enroll... COBRA Enrollment Form Please print or type in black or dark blue ink only. Please read the COBRA Information Sheet before submitting this form. Retain a copy for your records and to use as a temporary

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