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Dude dude dav30862 connects en... Enrollment Form Pleasecompletetheform,sign,andFAXto18558887206. Forassistance,callDALVANCECONNECTSSMat18553872824, MondaythroughFridayfrom8AMto8PMEasternTime. ServicesRequested Pleasecheckallthatapply:

2016 17 close up enrollment fo... 201617 CLOSE UP ENROLLMENT FORM Every participant must complete an enrollment form to participate in a Close Up Program. All students and minors should complete this form with a parent or guardian.

How to fill out a new york mem... New York Member Enrollment Form OHP MAILING ADDRESS: P.O. Box 29142, Hot Springs, AR 71903 18004446222 www.oxfordhealth.com Thank you for choosing an Oxford product for you and your family. IMPORTANT: PLEASE

Nj hint supplemental enrollmen... HINT Supplemental Enrollment Information Form Implementing P. L. 2005 c.375 Aetna Health Inc. underwrites for HMO and HNO products and the in-network component of the POS product. Insurance Company underwrites all other products. For Small Group Employers 2-50 lives Aetna Health Inc* underwrites all HMO HNO and POS products. A. Group Employee Information Group Name Group Number/Control Number Employee Name Employee s Aetna ID Number B. Type of Activity see Important Explanatory Information below Change - Check all that apply. Effective Date of Coverage date the coverage is to be effective Add young adult dependent over the limiting age but less than 31 / Remove young adult dependent over the limiting age but less than 31 Reason s NOTE all effective dates of coverage are subject to Aetna s standard policies and procedures. Billing Method Aetna will bill the young adult dependent directly. The young adult dependent will remit the premium directly to Aetna* Direct Bill young adult dependent add billing address required even if the same as the employee address Street Apt. Number City State ZIP Code C. Young Adult Dependent Information Name Last First MI Sex Birthdate MM/DD/YYYY M Other Health Coverage Primary Office ID Number Current Patient Yes No Previous Coverage Name of prior carrier F Other Rx Drug Coverage Ob/Gyn Office ID Number Dependent s Aetna ID Number N/A If yes provide the following information AND submit a copy of the Certificate of Creditable Coverage that was issued by the previous carrier if available Termination date of prior coverage Prior plan number D. Signatures I have read the important information below and agree to the conditions of enrollment. The information supplied in this application is true and complete to the best of my knowledge and belief* Employee Date IMPORTANT EXPLANATORY INFORMATION The employee must continue coverage in order for the young adult dependent to be covered* In addition the young adult must meet the applicable eligibility criteria below. The young adult dependent will be enrolled in their own plan* A young adult may request to continue or newly enroll as an over-age dependent on his or her parent s coverage even after the child reaches the limiting age under the terms of the policy if the adult child is not yet 31 years old is unmarried has no children lives in New Jersey or if not a New Jersey resident is a full-time student at an accredited institution of higher education is not eligible for Medicare and is not actually covered under another group or individual health plan* either when he or she has reaches the limiting age when he or she first becomes eligible for a reason other than reaching the limiting age for example the adult child becomes a full-time student in another state or returns to live in New Jersey after residing elsewhere or anytime the dependent meets the above eligibility requirements. Insurance Company underwrites all other products. For Small Group Employers 2-50 lives Aetna Health Inc* underwrites all HMO HNO and POS products. A. Group Employee Information Group Name Group Number/Control Number Employee Name Employee s Aetna ID Number B.

Dental provider enrollment 201... To avoid any delay of the enrollment process use this sheet as a checklist. For assistance with completing these forms call the TMHP Contact Center at 1-800-925-9126. To enroll as a provider of THSteps dental services a dentist must be currently licensed by the Texas State Board of Dental Examiners TSBDE and complete a Dental Provider Enrollment Application with TMHP. Obtain recertification as a Title XVIII Medicare facility under the new ownersh...

Enrollment form isagenix 2018... Com and may be provided to you via email. Please note that this form contains information to facilitate the enrollment process for new Isagenix members and is not intended as a substitute for full disclosure of membership terms and conditions. WELCOME TO ISAGENIX SOLUTIONS TO TRANSFORM LIVES Weight Loss These systems support healthy weight loss and muscle maintenance at nearly any age. Weight Loss Value Pak 30-Day Premium Pak Starting at 639/ about 22 per day Cleansing and Fat Burning System WEIGHT LOSS VALUE PAK 4 IsaLean Shakes or IsaLean PRO Shakes 2 Cleanse for Life 1 Ionix Supreme 1 Cleanse Support Bundle 1 e 6 count 1 Complete Essentials with IsaGenesis 1 IsaBlender 1 IsaDelight 1 Isagenix Greens 1 Whey Thins 1 IsaLean Bar Tool Kit Business Pak Free One-Year Membership Isagenix Event Certificate Welcome Kit Two Friends and Family Referral Coupons One 25 Product Coupon Weight-Loss System Guide 30-DAY PREMIUM PAK 4 IsaLean Shakes or IsaLean PRO Shakes 2 Cleanse for Life 1 Ionix Supreme 1 Cleanse Support Bundle 1 e 6 count 1 IsaBlender 1 IsaDelight 1 Whey Thins 1 IsaLean Bar 1 5-Piece Sample Pak Tool Kit Isagenix Event Certificate Weight-Loss System Guide WEIGHT LOSS 30-DAY CLEANSING AND FAT BURNING SYSTEM 4 IsaLean Shakes or IsaLean PRO 2 Cleanse for Life 1 Ionix Supreme 1 Cleanse Support Bundle 1 AMPED Hydrate 4-count sticks Juicy Orange Weight-Loss System Guide Energy These systems offer high-quality protein and nutrition to support health and energy throughout the day. Energy Value Pak Energy System ENERGY VALUE PAK 2 IsaLean Shakes or IsaLean PRO 1 Complete Essentials Daily Pack 1 Ionix Supreme 1 IsaLean Bar 1 AMPED Hydrate 4 e 6 count 1 IsaDelight 1 Fiber Snacks 1 Isagenix Greens canister only 1 Isagenix Coffee 1 IsaBlender 3 5-Piece Sample Paks 1 Sleep Support Renewal 1 CytoActives 2 AMPED Hydrate 4-count sticks Juicy Orange Tool Kit Business Pak Free One-Year Membership Isagenix Event Certificate Welcome Kit Energy System Guide ENERGY SYSTEM 2 IsaLean Shakes or IsaLean PRO 1 Ionix Supreme 2 IsaLean Bar 1 AMPED Hydrate 4-count sticks Juicy Orange 2 e 6 count 1 IsaDelight 1 Fiber Snacks 1 Isagenix Coffee 1 Sleep Support Renewal Energy System Guide Performance Value Pak PERFORMANCE VALUE PAK 2 e 6 count 1 AMPED Nitro 1 AMPED NOx 1 AMPED Fuel 1 AMPED Hydrate 1 AMPED Recover 2 IsaLean PRO 2 IsaPro 1 Ionix Supreme 1 AMPED Protein Bar 1 Complete Essentials Daily Pack 1 Isagenix Event Certificate Tool Kit Business Pak Free One-Year Membership Welcome Kit 2 5-Piece Sample Pak includes IsaShaker 1 IsaBlender Performance System Guide PERFORMANCE SYSTEM 1 e 6 count 1 AMPED Nitro 1 AMPED NOx 1 AMPED Hydrate 1 AMPED Recover 2 IsaLean PRO 1 AMPED Protein Bar 1 Ionix Supreme Performance System Guide Healthy Aging and Telomere Support System HEALTHY AGING VALUE PAK 1 Ionix Supreme 1 Cleanse for Life 2 IsaLean Shakes or IsaLean PRO 1 Complete Essentials with IsaGenesis 1 Brain Boost Renewal 1 IsaDelight 1 Rejuvity Sampler 1 4-Day Cleanse Support Kit 1 IsaBlender 1 IsaGenesis 1 e 6 count 1 IsaLean Bar 1 5-Piece Sample Pak Tool Kit Business Pak Isagenix Event Certificate Free One-Year Membership Welcome Kit Pricing and System and Pak components are subject to availability and may be changed at any time.

Benefits fund enrollment form... New York State Nurses Association N Y S N A Benefits Fund PO Box 12430 Albany, NY 122122430 (877) RN BENEFITS www.rnbenefits.org Social Security Number Code (To be filled out by Fund office) Benefits

State of nebraska substitute f... Clear Form ReturnFormtothe Requester. (Rev.December2014) STATE OF NEBRASKA SUBSTITUTE FORM W9 & ACH ENROLLMENT FORM Requester Information: (State of Nebraska Agency requesting this form to be

Palmetto gba jm part a part a... The Part A/Part B EDI Enrollment packet contains forms and explanations for each of the services offered by our Electronic Data Interchange EDI department. Please visit the eServices webpage at www. PalmettoGBA. com/eServices for function availability and registration information. To be eligible to participate in eServices you must have a completed an EDI Enrollment Agreement included in the packet that is actively on file with Palmetto GBA. Part A/Part B/HHH EDI Enrollment Packet Attention Please Read Before Completing Paperwork This enrollment packet is for use in the following Jurisdictions/states Jurisdiction J Parts A and B Alabama Georgia and Tennessee Parts A and B South Carolina North Carolina Virginia and West Virginia Home Health Hospice HHH Alabama Arkansas Florida Georgia Illinois Indiana Kentucky Louisiana Mississippi New Mexico North Carolina Ohio Oklahoma South Carolina Tennessee and Texas Review Choice Demonstration RCD for HHH Illinois VA WV Part A Palmetto GBA has subcontracted with National Government Services NGS to continue EDI support of the Virginia and West Virginia Part A workload for Palmetto GBA. Please contact the NGS Help Desk at 855-696-0705 for EDI support. Enrollment Submission We are now accepting completed enrollment paperwork via fax or email do not submit more than once. 803-870-0163 EDIENROLL*PARTA PalmettoGBA. com 803-699-2429 EDIPartA. ENROLL PalmettoGBA. com Email Enrollment Monitoring Your email address will be the primary method of communication with Palmetto GBA EDI Operations. We will send you a Tracking Number via email that you can use to monitor your enrollment process through the website at www. palmettogba*com/EDI. Be sure to include your email address on all EDI Enrollment forms. Please add palmettogba*com and bcbssc*com to your email contact list to ensure our emails are not filtered into your spam or junk mail folder. Take Control of your Accounts Receivable and Become Compliant Now Sign up today to receive your remittances electronically and be ahead of the game. Download and print your remits more quickly. CMS is focused on increasing the number of providers who receive their remittances electronically and decreasing the printing and mailing costs associated with hardcopy remittances. Complete your forms today Support We are committed to making your transition to EMC as smooth as possible. If you have any questions regarding the information contained in this package please feel free to contact the Palmetto GBA EDI Provider Contact Center toll free at Thank you for your interest in Electronic Data Interchange Palmetto GBA www. palmettogba*com A CMS Medicare Administrative Contractor Using Electronic Data Interchange Services administers the Part A Part B contracts for Alabama Georgia South Carolina North Carolina Tennessee Virginia and West Virginia in addition to home health and hospice HHH services provided in the following states Alabama Arkansas Florida Georgia Illinois Indiana Kentucky Texas.

This enrollment packet is for... The Part A/Part B EDI Enrollment packet contains forms and explanations for each of the services offered by our Electronic Data Interchange EDI department. Please visit the eServices webpage at www. PalmettoGBA. com/eServices for function availability and registration information. To be eligible to participate in eServices you must have a completed an EDI Enrollment Agreement included in the packet that is actively on file with Palmetto GBA. Part A/Part B/HHH EDI Enrollment Packet Attention Please Read Before Completing Paperwork This enrollment packet is for use in the following Jurisdictions/states Jurisdiction J Parts A and B Alabama Georgia and Tennessee Parts A and B South Carolina North Carolina Virginia and West Virginia HHH Alabama Arkansas Florida Georgia Illinois Indiana Kentucky Louisiana Mississippi New Mexico North Carolina Ohio Oklahoma South Carolina Tennessee and Texas VA WV Part A Palmetto GBA has subcontracted with National Government Services NGS to continue EDI support of the Virginia and West Virginia Part A workload for Palmetto GBA. Please contact the NGS Help Desk at 855-696-0705 for EDI support. Enrollment Submission We are now accepting completed enrollment paperwork via fax or email do not submit more than once. 803-870-0163 EDIENROLL*PARTA PalmettoGBA. com 803-699-2429 EDIPartA. ENROLL PalmettoGBA. com Email Enrollment Monitoring Your email address will be the primary method of communication with Palmetto GBA EDI Operations. We will send you a Tracking Number via email that you can use to monitor your enrollment process through the website at www. palmettogba*com/EDI. Be sure to include your email address on all EDI Enrollment forms. Please add palmettogba*com and bcbssc*com to your email contact list to ensure our emails are not filtered into your spam or junk mail folder. Take Control of your Accounts Receivable and Become Compliant Now Sign up today to receive your remittances electronically and be ahead of the game. Download and print your remits more quickly. CMS is focused on increasing the number of providers who receive their remittances electronically and decreasing the printing and mailing costs associated with hardcopy remittances. Complete your forms today Support We are committed to making your transition to EMC as smooth as possible. If you have any questions regarding the information contained in this package please feel free to contact the Palmetto GBA EDI Provider Contact Center toll free at Thank you for your interest in Electronic Data Interchange Palmetto GBA www. palmettogba*com A CMS Medicare Administrative Contractor Using Electronic Data Interchange Services administers the Part A Part B contracts for Alabama Georgia South Carolina North Carolina Tennessee Virginia and West Virginia in addition to home health and hospice HHH services provided in the following states Alabama Arkansas Florida Georgia Illinois Indiana Kentucky Louisiana Mississippi New Mexico North Carolina Ohio Oklahoma South Carolina Tennessee and Texas.

Undergraduate special enrollme... Office of the Registrar Ochre Court, Room 203 100 Ochre Point Avenue Newport, RI 028404192 Tel: 4013412943 * Fax: 4013412996 sruregistrar salve.eduUNDERGRADUATE SPECIAL ENROLLMENT FORM This form is

1199seiu enrollment 2006 form -1035 -1035 -1035 SECTION 2 NEW DEPENDENTS(S) Dependiente(s) Nuevo(s) ? ADD ELIGIBLE CHILD(REN) Agregar sus hijos(as) que son eligible: SEX Sexo 1 LAST NAME Apellido FIRST NAME Nombre Initial Inicial

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