ONCE THE FORM IS COMPLETED, RETAIN THE LAST COPY FOR YOUR RECORDS.
17) First Name, Middle Initial and Last Name – Complete the first name, middle initial and
last name for each eligible person listed.
18) Social Security Number – Please include the Social Security Number of each person.
19) Do you have other insurance? – If you or a family member have other medical
insurance, including Medicare, respond “Yes”. If not, you must
respond “No”.
20) Birth Date (month, day, century and year).
21) Sex (Female or Male)
22) Check If: Student over Maximum Regular Dependent Age, Disabled and/or Act 4
dependent – If your dependent is over the Maximum Regular Dependent Age and is a
full time student or a disabled dependent of any age or an Act 4 dependent to the age
of 30 (see your benefit administrator for eligibility), please check (✔) the appropriate
column by that dependent’s name.
23) Full Name of Primary Care Physician (PCP) / Group Practice from Directory – Indicate the
name of the Primary Care Physician (PCP) or Group Practice selected from the Provider
Directory for yourself and each of your dependents. You and your dependents can each
choose a different PCP.
24) Are you an existing Patient of this PCP? – Please check “
Yes” or “No” to indicate if you are
currently a patient of the PCP you chose.
25) Primary Care Physician (PCP) Number from Directory – Please indicate the corresponding
number for the physician you or your dependent chose as a PCP from the Provider Directory.
26) Directory Network Code – Please indicate the Directory Network Code which is located on
the front cover of your Provider Directory.
27) Complete if you, your spouse/domestic partner or one of your eligible dependents has other
health insurance coverage or is eligible for Medicare. Refer to your Medicare card to
complete the Medicare Information Section.
28) Your employer and you must sign and date the form where indicated.
EMPLOYEE INFORMATION
Items 1 through 5 and 10 through 14 ask for information regarding the employee. The
information you must complete includes:
1) Reason for Application – Please check the appropriate box indicating reason for
application.
2) Employee Hire Date (i.e., date employee first eligible to enroll for benefits) – Specify
month/day/year. Required under the Health Insurance Portability and Accountability
Act of 1996 (HIPAA).
3) Employee Status: Please check the appropriate box(es) indicating whether you are an
Active, Retired, Hourly or Salary employee. If retired, please indicate retirement date.
4) Employee Home Phone Number (including area code) – Please provide so that we may
contact you if we have questions about your application and to better serve you.
5) Employee Work Phone Number (including area code)
Items 6 through 9 should be completed by your Account Administrator
.
10) Employer Name.
11) Association Name – Please indicate if your Employer is part of an association.
12) Employee First Name, Middle Initial and Last Name.
13) Social Security Number
14) Employee Street Address, City, State, and Zip Code.
15) Check or write in Type of Product and Type of Coverage for which you are enrolling
using the appropriate category (employee, insured & spouse/domestic partner, parent
and child, parent and children, or family).
Items 16 through 26 ask for important information about yourself and each
eligible member of your family. Please complete the following information for yourself,
your spouse/domestic partner, or your child/dependent. Please indicate the relationship
to the employee according to the Relation Codes provided below the ELIGIBLE
PARTICIPANTS section.
16) Relation Code – Please indicate the appropriate Relation Code for each eligible
participant. Please refer to the key (*) provided on the application below the
ELIGIBLE PARTICIPANTS section.
HOW TO COMPLETE YOUR ENROLLMENT APPLICATION
Following are instructions for completing the Enrollment Application.
Remove instruction sheet to complete application.
All information must be completed as indicated.
ENROLL-4 (12-15)
For employers with more than 50 employees located in these Northeastern PA counties: Bradford, Carbon, Clinton, Lackawanna, Luzerne, Lycoming, Monroe, Pike, Sullivan, Susquehanna, Tioga, Wayne and Wyoming.
