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Thank you for choosing Harvard Pilgrim Health Care.
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Please read the following instructions prior to completing this enrollment/change form. This form may be used for all enrollment
transactions (Adding coverage, changing coverage, terminating coverage). In order to add, change or terminate coverage you must (1)
experience a qualifying event, (2) complete this enrollment, and (3) provide the completed form to your employer within the allowed
timeframe or approved retroactive period.
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Qualifying Events:
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Employer Section: Your Employer must fill out this section as well as the Reason for Submission in full for any transactions that this
form is used for.
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Member Section: Please complete all of the employee sections of this membership application in full. Failure to do so could delay
enrollment. You will receive your ID card(s) and member benefit documents after your enrollment has been fully processed. If you are
adding or removing a dependent(s), just include the details about the dependent(s) that you are adding or removing off the plan.
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Product/Plan Name: Please be sure to fill in the correct product code for the plan you have selected. Your options are HMO,
POS, PPO and Access America. If your employer offers multiple Harvard Pilgrim Plans, please indicate the Plan name as
listed on the enrollment materials to help clearly differentiate the plan you are choosing. If you know the Plan MD #
(MD0000016670) the number to identify the plan/product please include the information.
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Personal Information: In addition to yourself, please include the personal information for every dependent that will be
enrolled
on the Plan. IMPORTANT: Social security numbers (or personal tax identification number) for each member on
the plan are
needed to ensure that federal regulatory reporting requirements are met. Social security numbers are not
displayed on the
member’s ID card.
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Primary Care Provider: If your plan is an HMO, you will need to select a primary care provider (PCP). If your plan
requires
one, it is important that you choose a PCP right away. Be sure to fill out this section for all members, including
dependents.
Write the Harvard Pilgrim PCP ID (not the phone number) and the full name of the doctor you have chosen to
coordinate your
health care without a PCP assignment, your in-network benefits may be limited to emergency services only. To find
a PCP or
lookup the PCP ID, visit www.harvardpilgrim.org, and use the doctor search feature available in the Member Section.
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Relation Code: Please use one of the following codes to designate the dependent’s relationship to the Employee:
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02 Spouse/Civil Union
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03 Child up to age 26
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06 Disabled (verification required)
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07 Ex-spouse
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DP Domestic Partner
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SE Spousal Equivalent
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When this application is complete: Please sign the enrollment form and provide it to your employer. Your employer will need to sign
this form and will forward this application to Harvard Pilgrim Health Care for processing. If you need additional assistance
completing this form or selecting a PCP, please call a member services coordinator at 1-888-333-4742.
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Coverage underwritten or administered by Harvard Pilgrim Health Care. Harvard Pilgrim Health Care includes Harvard Pilgrim
Health Care, Harvard Pilgrim Health Care of Connecticut, Harvard Pilgrim Health Care of New England and HPHC Insurance
Company.
