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Benefits fund open enrollment... New York State Nurses Association N Y S N A Benefits Fund PO Box 12430 Albany, NY 12212-2430 (877) RN BENEFITS www.rnbenefits.org Social Security Number ? Code (To be filled out by Fund office) Benefits

Patient enrollment form PLEASE REVIEW MEDICATION GUIDE WITH PATIENTS. VIV-001548 PAGE 2 If you have requested injection services for your patient Touchpoints will provide a selection of several injectors based on geographic proximity to your patient s address listed on the enrollment form from closest to farthest from such address. These injection providers are listed on the Provider Locator ll at www. .com. These options will be provided to you for your patient. We will also contact the selected injection services provider to help coordinate injection services. ll Enrollment in the Locator is voluntary and free of charge and along with the provider-specific information in the Provider Locator is based on healthcare provider responses. I understand that Alkermes reserves the right at any time and for any reason without notice to modify this Touchpoints enrollment form or to modify or discontinue any services or assistance provided through Touchpoints. Finally I authorize Alkermes United BioSource Corporation Armada Health Care LLC and OPUS Health as my designated agents to use and disclose my patient s health information as necessary to verify the accuracy of any information provided to provide reimbursement services through Touchpoints to forward the above prescription by fax or other mode of delivery to a pharmacy for fulfillment and as applicable to assess my patient s eligibility for co-pay assistance. 00 303. 91 304. 03 304. 72 PHARMACY BENEFIT PLAN PBM PBM Name Other Patient has tried and failed the following medication s Please list any known allergies to medications or other substances PBM Phone Rx BIN PRESCRIPTION INFORMATION Patient Name Date 380 mg x 1 unit Inject 380 mg IM q4 weeks or q1 month Provider State License Refill times PROVIDER ATTESTATION Prescriber signature must be the same as the prescriber name above Date of Signature By signing above I verify that the information provided in this Touchpoints enrollment form is complete and accurate to the best of my knowledge. PATIENT ENROLLMENT FAX COMPLETED FORM TO 1-877-329-8484 PLEASE COMPLETE ALL FIELDS TO AVOID PROCESSING DELAYS TOUCHPOINTS PHONE 1-800-848-4876 TP ID TOUCHPOINTS USE ONLY PRESCRIBER INFORMATION INJECTION PROVIDER INFORMATION Prescriber Name Will your office/facility be injecting Prescriber Tax ID State License NPI Prescriber Phone Yes ALL doses DEA Fax No please locate an Injection Provider or refer to Provider below Provider Name Provider Address Facility Name Provider Phone Address City State Zip Code Staff Contact Name Staff Contact Phone PATIENT INFORMATION Name Preferred specialty pharmacy if applicable Special shipping instructions/restrictions PATIENT INSURANCE INFORMATION First Last Date of Birth Payment Method Insured Paying out-of-pocket Gender Male Female ATTACH A COPY OF BOTH SIDES OF THE PATIENT S INSURANCE CARD S. Home Phone Mobile Phone Best Day to Call M T Best Time to Call Morning W TH Afternoon IF NOT AVAILABLE COMPLETE SECTION BELOW* PRIMARY INSURANCE Insurance Type HMO PPO Medicaid Medicare F Evening Carrier Name Policyholder Name Email Address INSTRUCT PATIENT TO LIST ALTERNATE DESIGNEE OR CONTACTS ON PAGE 2.

Texas blue cross blue shield a... N Spouse n Child I am an employee of the Employer named in this Enrollment Application. I am eligible to participate in the coverage s afforded by my Employer s plan which is either underwritten or administered by Blue Cross and Blue Shield of Texas BCBSTX or Dearborn National Life Insurance Company. Enrollment Application/Change Form Please read the instructions on the inside thoroughly before completing this enrollment application/change form* 54521. 0913 ENROLLMENT APPLICATION /CHANGE FORM INSTRUCTIONS PLEASE READ THOROUGHLY BEFORE COMPLETING ENROLLMENT APPLICATION / CHANGE FORM Use a black or blue ballpoint pen only. Print neatly. Do not abbreviate. Please Note If your group offers a Consumer Choice health plan you have the option to choose a Consumer Choice of Benefits Health Insurance Plan or Consumer Choice of Benefits Health Maintenance Organization health care plan that either in whole or in part does not provide state-mandated health benefits normally required in accident and sickness insurance policies or evidences of coverage in Texas. This standard health benefit plan may provide a more affordable health insurance policy or health plan for you although at the same time it may provide you with fewer health benefits than those normally included as state-mandated health benefits in policies or evidences of coverage in Texas. If you choose this standard health benefit plan please consult with your insurance agent to discover which state-mandated health benefits are excluded in this policy or evidence of coverage Certificate of Coverage. SECTION 1 Check all the boxes that apply to indicate if you are a new enrollee or if you are requesting a change to your coverage. Indicate the event and date if applicable. Complete the additional sections that correspond to your selection* New Enrollee Complete all Sections where applicable. Add Dependent Complete all Sections where applicable. If you are enrolling a court-ordered dependent for coverage beyond the automatic 31 day period for coverage you must submit a copy of the court order or decree. If student dependent coverage is part of your employer s plan and you are adding or enrolling a dependent child age 26 or over who is a student you may be required to submit a completed Student Certification form* If you are applying for coverage for a disabled dependent over the age limit of your employer s plan please provide the additional information requested in Section 6. Additional documentation may be required as addressed in that section* Cancel Enrollee Complete Sections 1 2 4 and 10. In Section 4 include name social security number and date of birth of individual s cancelling. Cancel Dependent Complete Sections 1 2 4 and 10. In Section 4 include name and date of birth of individual s cancelling. Declining Coverage Complete Sections 2 9 and 10. SECTIONS 2 3 Complete all portions related to the coverages for which you are applying. If you work for an employer with 2-50 employees Please list the seven-character plan ID for your selected benefit design example B634ADT in the Plan field.

Enrollment form isagenix I Would Like Monthly Autoship Yes No HEALTHY AGING PRESIDENT S PAK 2 IsaLean Shake 1 Ageless Essentials with Product B IsaGenesis men or women 1 Ionix Supreme 1 Cleanse for Life 1 2-Day Cleanse Support Kit 1 Product B IsaGenesis - 120ct Marketing Tools Isagenix Event Certificate 1 Free one-year membership 1 System Guide with CD PERFORMANCE PRESIDENT S PAK 2 IsaLean Pro - 14 count 1 IsaLean Shake 1 IsaPro 1 Ageless Essentials with Product B IsaGenesis men or women 1 Ionix Supreme Tablets 1 Sleep Spray 2 5-piece Sample Pak 1 IsaBlender REJUVITY PRESIDENT S PAK 1 Purifying Cleanser 1 Hydrating Toner 1 Essential Youth Serum 1 Age-Defying Eye Cream 1 Moisturizing Day Cream 1 Renewing Night Cream 1 Bamboo Exfoliating Polish 1 Rejuvity Cosmetic Travel Bag 1 Rejuvity Skincare Sample Paks 10ct 2 IsaLean Shake 1 Ionix Supreme 1 Cleanse for Life 1 Ageless Essentials men or women 1 IsaDelight Plus - 30ct milk or dark 1 2-Day Cleanse Support Kit 1 Free one-year membership 1 System Guide WEIGHT LOSS 30-DAY CLEANSING AND FAT BURNING SYSTEM 4 IsaLean Shake 2 Cleanse for Life 1 Ionix Supreme 1 Isagenix Snacks 1 Natural Accelerator 1 IsaFlush 4 Want More Energy sticks orange 1 System Guide with CD HEALTHY AGING AND TELOMERE SUPPORT SYSTEM Essentials with Product B IsaGenesis men or women 1 2-Day Cleanse Support Kit 1 System Guide with CD ENERGY AND PERFORMANCE SYSTEM Pack men or women 1 Ionix Supreme 1 IsaLean Bars - 10ct 1 Want More Energy 1 e - 6ct 1 System Guide with CD REJUVITY SKINCARE SYSTEM WITH AGELESS ESSENTIAL DAILY PACK 1 Age-Defying Eye Cream 1 Moisturizing Day Cream 1 Renewing Night Cream 1 Bamboo Exfoliating Polish 1 Rejuvity Cosmetic Travel Bag 1 Ageless Essentials Daily Pack men or women Autoship Order Your monthly product choice Preferences Flavor Shakes/Snacks Chocolate Vanilla Dairy-Free Berry Black Sesame IsaDelight Plus Whey Thins Barbecue Sour Cream Chive Chocolate Peanut Crunch Chocolate Cream Crisp Chocolate Decadence Lemon Passion Crunch Natural Oatmeal Raisin Nutty Caramel Cashew Form Container Powder Liquid Canister Packets Male Female I understand by signing above I have read and agree to abide by the Isagenix Policies Procedures/ Terms and Conditions and that this enrollment form is abbreviated and not intended as a substitute for full disclosure of the Isagenix Policies Procedures/Terms and Conditions. WELCOME TO ISAGENIX SOLUTIONS TO TRANSFORM LIVES BUSINESS BUILDER PAK NEW MEMBER REWARDS 1 099 RETAIL OVER 1 400 BV 640 The Business Builder Pak This ultimate business-building pak includes our flagship 30-Day Cleansing and Fat Burning System and additional performance products incomparable age-defying products best selling nutritional solutions and some of our top marketing tools. Free 39 Membership 1 Business Pak Tool Kit Event Gift Certificate IsaBody Look Book 1 IsaBlender 2 Welcome Kits Largest variety of products Free International Membership 49 value PRESIDENT S/VALUE PAKS NEW MEMBER REWARDS 559 RETAIL OVER 700 BV 320 Weight Loss President s Pak This pak has plenty of products to share with friends and family who are interested in healthy weight loss better body composition and optimum health.

Hickory county r 1 schools stu... Welcome to Skyline Middle School! Things you will need to bring with you to enroll your child in school: * Complete and up-to-date shot records * Copy of Birth Certificate * Copy of Social Security

Patient enrollment forms needy... Form from www.needymeds.org Reset Form () for Injection is indicated for the treatment of pulmonary arterial hypertension (PAH) (WHO Group 1) to improve exercise capacity. Studies

Enrollment form young living e... Enrollment Form Name: Email Phone Address (Street, City, St, Zip) Ordering Account Set Up: PIN (4 digit) User Name: Password: (8-12 characters with number) Person who introduced you to Young Living:

Hmsa enrollment form HMSA MEDICAL/DENTAL PLAN ENROLLMENT FORM PLEASE PRINT OR TYPE IN BLUE OR BLACK INK. REFER TO THE BACK FOR ENROLLMENT INSTRUCTIONS. A Group No. Employer EMPLOYEE DATA FOR HMSA USE ONLY Last Name First Legal M. HMSA. com and click on Find a Doctor. SECTION D - OTHER INSURANCE Check Yes to indicate if you your spouse or any of your dependents are also covered by any other group health plan including HMSA or Medicare. If you check Yes enter the other policy holder s name the other policy holder s ID number the name of the other health plan and a phone number for the other health plan. SECTION E - CONDITIONS FOR ENROLLMENT sign and date the enrollment form.. COMPLETE THIS SECTION IF YOU SELECTED AN HMO MEDICAL PLAN over age 18 See Sec C on reverse side Personal Care Physician Employee Self Yes Child DO YOU OR YOUR DEPENDENTS HAVE OTHER COVERAGE INCLUDING HMSA Name of Other Policy Holder E CONDITIONS OF ENROLLMENT Y/N OTHER INSURANCE Spouse D Current Physician YES Other Policy Holder s ID No. NO IF YES COMPLETE THE FOLLOWING Name of Other Health Plan Other Health Plan s Phone Number READ SIGN AND DATE BELOW. If I am accepted for coverage under a medical plan that requires selection of a personal care physician all benefits must be provided or arranged by my personal care physician. I further understand that as an HMSA member I agree a to abide by the HMSA s constitution and by-laws and terms and conditions of the health/dental plan b to provide information to HMSA about my current or future medical treatment or condition and c to appoint my employer or group as my agent for dues payment and for sending and receiving all notices to and from HMSA concerning the health/dental plan. Signature Form No. 4000-005 02/09 Date // SEE REVERSE SIDE White - HMSA Yellow - HMSA/OPL Pink - GROUP ENROLLMENT INSTRUCTIONS Complete all applicable fields to minimize delay in processing. You may not be entitled to all of the plans shown on this enrollment form. Only select plans that your employer states are available. I. Suffix Gender Birthdate mm/dd/yyyy Work Phone No* SUB ID NO. M/F Mailing Address Number Street or P. O. Box Number City State EFF* DATE GROUP NO. Zip Code Home Phone No* CONT PKG DEPT. NO. APP RCV DATE PROC DATE Social Security No* See Section A on reverse side for additional information on submission of SSN B SELECTING YOUR COVERAGE My Present or Former HMSA No* If you are currently the subscriber of an HMSA Individual Plan and wish to cancel that membership please submit a separate cancellation request in writing. TRX PLEASE CHECK WITH YOUR EMPLOYER REGARDING THE MEDICAL AND DENTAL PLAN OPTIONS* HMSA s Choice Medical Plan Select one Free Choice Medical Plan HMSA s Choice Dental Plan Select one HMO Medical Plan Preferred Provider Plan HMO Dental Plan Free Choice Dental Plan Health Plan Hawaii Plus Participating Provider Dental Program Dental Network Program If selecting this plan indicate desired Health Center AND Personal Care Physician in Section C below C ENROLLMENT DATA IF YOU SELECTED AN HMO MEDICAL PLAN ENTER A HEALTH CENTER AND PERSONAL CARE PHYSICIAN FOR YOU AND YOUR DEPENDENTS* LEGAL NAME BIRTHDATE First Name mm dd yyyy Full Time Student SOCIAL SECURITY NO.

Preferred customer enrollment... USA Fax 855.676.9280 pcsupport lifevantage.com PREFERRED CUSTOMER APPLICATION Preferred Customer Information *Required Information (Please Print Clearly) Co-Applicant *First Name and Last Name *First

Meridianrx electronic funds tr... MeridianRx Electronic Funds Transfer (EFT) Enrollment Form Note: Pharmacy is not eligible for EFT if you are receiving your payments through a Pharmacy Services Administrative Organization (PSAO)

United health care enrollment... (DO NOT STAPLE) Employee Enrollment Form To speed the enrollment process, please be thorough and fill out all sections that apply. UnitedHealthcare Insurance Company UnitedHealthcare of Texas, Inc.

Nics enrollment form The FBI has created the NICS Enrollment Form so that it is easily understood and requires the least possible burden on you to provide us with information. The reporting burden for collection of information on the NICS Enrollment Form is computed as 1 learning about the documents 2 minutes 2 completing the NICS Enrollment Form 3 minutes 3 assembling mailing faxing or e-mailing the form to the FBI 3 minutes for an estimated average of 8 minutes per response. When adding additional users you may assign them the user role you deem necessary. The enrollment form can be faxed to 888 550-6427 e-mailed to nicscommandcenter ic.fbi. gov or mailed to the Federal Bureau of Investigation NICS Section P. O. Box 4278 Clarksburg West Virginia 26302. NAME OF FFL EMPLOYEE WHO WILL BE ACCESSING THE FBI NICS E-CHECK This employee will be an administrative user and can add additional users as necessary. When adding additional users you may assign them the user role you deem necessary. The enrollment form can be faxed to 888 550-6427 e-mailed to nicscommandcenter ic.fbi. Federal Bureau of Investigation National Instant Criminal Background Check System NICS Federal Firearms Licensee FFL Enrollment / NICS E-Check Enrollment Form OMB NO. To submit comments regarding the accuracy of the estimates to provide suggestions for making this form simpler or to enroll by providing this form you can submit it to the NICS Section by fax at 888 550-6427 by e-mail to nicsfflemail ic.fbi. E-MAIL ADDRESS 9. POINT OF CONTACT PERSON If different than Item 4 above LAST NAME 11. BUSINESS FAX NUMBER optional FBI NICS E-Check Users Complete this Section Every FFL wanting to use the FBI NICS E-Check must complete and submit by fax e-mail or mail this entire form and provide the following additional information 12 and 13 below. The information collected may be shared with other government agencies for authorized purposes and with certain other persons and entities for other purposes as provided for in the most recently published routine uses for the NICS Justice/FBI-018. The form requests both mandatory and optional information. If you omit mandatory information we may not be able to process your request. 14. User/Applicant Signature 15. FFL Witness Date executed FEDERAL FIREARMS LICENSEE FFL ENROLLMENT FORM ITEMS FFL NUMBER This is the 15 digit number assigned by the Bureau of Alcohol Tobacco Firearms and Explosives. CODE WORD This is a code word of your choice to be used as a verification of identity when you contact the NICS Section. The code word MUST be between 6 and 10 characters in length and can include both numbers and letters. 1110-0026 Please TYPE or PRINT neatly in BLACK INK using UPPERCASE letters. 1. FFL NUMBER Note 03 Licensees need not enroll - 2. CODE WORD Must be six to ten characters - NO PROFANITY 3. BUSINESS PHONE NUMBER 4. NAME OF FFL Name that appears on FFL License. If company name place in LAST Name block and place overflow in FIRST and MI blocks-if necessary. LAST NAME LICENSEE NAME FIRST NAME MI CADENCE 5.

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