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.
1. REASON FOR APPLICATION
ENROLLMENT
NEW HIRE REHIRE COBRA
OTHER:
12. EMPLOYEE’S FIRST NAME MIDDLE INITIAL LAST NAME 13. SOCIAL SECURITY NUMBER
10. EMPLOYER NAME
14. ADDRESS - STREET CITY STATE ZIP
15. CHECK TYPE OF EMPLOYEE INSURED & SPOUSE/ PARENT & PARENT & FAMILY
COVERAGE EMPLOYEE ONLY DOMESTIC PARTNER CHILD CHILDREN
IS SELECTING:
HMO ❑❑
POS ❑❑
PRODUCT NAME: ❑❑
DENTAL ❑❑
VISION ❑❑
DRUG ❑❑
11. ASSOCIATION NAME - IF APPLICABLE
2. EMPLOYEE HIRE DATE 6. EFFECTIVE DATE3. EMPLOYEE STATUS
ACTIVE HOURLY SALARY
RETIRED (DATE)
4. HOME TELEPHONE #
( )
5. WORK TELEPHONE #
( )
7. GROUP NUMBER 8. REPORT CODE
QUALIFIER
9. REPORT CODE
VALUE
ENROLLMENT APPLICATION
PLEASE PRINT (COMPLETE ALL BUT THE SHADED AREAS)
ENROLL-4 (12-15)
Membership Department
P.O. Box 535193
Pittsburgh, PA 15253-5193
Complete items 16 through 26 where applicable. List eligible participants (If you have additional dependents, attach separate sheet)
16. Complete
Where
Applicable
Self
20. Birth Date
Mo Dy Yr
21.
Sex
F/M
Student
Benefits
Apply
Dis-
abled
22. Check If
18. Social Security Number
17. First Name / Middle Initial / Last Name
Child
Other*
Spouse
Dom. Part.*
Child
Other*
Child
Other*
*If “domestic partner” or “other” applies, complete using one of the following codes: (05) Grandchild, (07) Nephew or Niece, (17) Stepson or Stepdaughter, (29) Domestic Partner
27. If you checked YES to other insurance, fill in appropriate line:
Name of Insurance Carrier:
Group No: Effective Date:
Name of Policy Holder:
Policy Number:
Relationship to Highmark Policy Holder:
Policy Holder Date of Birth:
Policy Holder Employment Status: Active Retired (Date)
MEDICARE INFORMATION: List any family member that is eligible for Medicare Benefits:
Name of Member Health Insurance Part A Effective Part B Effective Part D Effective
LastFirst Claim Number Date (Mo-Day-Yr) Date (Mo-Day-Yr) Date (Mo-Day-Yr)
/ / / / / /
/ / / / / /
/ / / / / /
Why are you eligible for Medicare? Age Disability End Stage Renal Disease
Do you have a Medicare Supplement or other coverage that complements Medicare?
Yes
No
Yes No
If YES, then
complete #27
19. Do you
have other
insurance?
Yes No
If YES, then
complete #27
Yes No
If YES, then
complete #27
Yes No
If YES, then
complete #27
Yes No
If YES, then
complete #27
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
23. Full Name of Primary
Care Physician (PCP)
24.
Established
Patient?
25. PCP Number
from Directory
26.
Directory
Network
Code
Authorized Employer Signature Date
28.
Employee Signature Date
coverage and recognize that I must formally enroll my dependents on this form or they will not be covered.
I acknowledge and agree that any personally identifiable health information about me or my enrolled dependents (“Protected Health
Information”) is protected by The Health Insurance Portability and Accountability Act of 1996 (HIPAA) and other privacy laws, and that, in
accordance with those laws. Highmark Blue Cross Blue Shield or Highmark Choice Company (Highmark) may use and disclose Protected
Health Information for payment, treatment and health care operations as described in its Notice of Privacy Practices. I understand that a
copy of Highmark’s Notice of Privacy Practices is available on Highmark’s web site, or from the Highmark Privacy Office.
To the best of my knowledge and belief, the information provided on this application is true and correct. Any person who
knowingly and with intent to defraud any insurance company or other person files an application for insurance or
statement of claim containing any materially false information or conceals for the purpose of misleading, information
concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to
criminal and civil penalties. I understand that this form enrolls those eligible persons listed above in the Medical Plan as
described in the agreement between the plan and my employer. I authorize any payroll deductions required for the
SHADED AREAS TO BE COMPLETED BY ACCOUNT ADMINISTRATOR ONLY
Act
4
Insurance or benefit administration may be provided by Highmark Blue Cross Blue Shield, First Priority Health, or First Priority Life Insurance Company.
Information is issued by Highmark Blue Cross Blue Shield on behalf of these companies, which are independent licensees of the Blue Cross and Blue Shield Association
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