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Form preview 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.
Form preview 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
Form preview 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
Form preview 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
Form preview 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
Form preview 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
Form preview 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
Form preview 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: - -
Form preview 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.
Form preview 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
Form preview 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
Form preview 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.

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