Fillable Highmark PPO Enrollment Form Rev041416 Highmark BCBS 1c (Wilkes University)

Fill Online, Printable, Fillable, Blank Highmark PPO Enrollment Form Rev041416 Highmark BCBS 1c (Wilkes University) Form

Use Fill to complete blank online WILKES UNIVERSITY pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Highmark PPO Enrollment Form Rev041416 Highmark BCBS 1c (Wilkes University)

On average this form takes 34 minutes to complete

The Highmark PPO Enrollment Form Rev041416 Highmark BCBS 1c (Wilkes University) form is 2 pages long and contains:

  • 0 signatures
  • 50 check-boxes
  • 112 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Wilkes University

BROWSE WILKES UNIVERSITY FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
HOW TO COMPLETE YOUR HIGHMARK BLUE CROSS BLUE SHIELD ENROLLMENT APPLICATION
FOLLOWING ARE INSTRUCTIONS FOR COMPLETING THE HIGHMARK BLUE CROSS BLUE SHIELD ENROLLMENT APPLICATION.
ALL INFORMATION MUST BE COMPLETED AS INDICATED.
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
JD-8 (12-15)
EMPLOYEE INFORMATION
The first thirteen (13) items ask for information regarding
the employee. The information you must complete includes:
1) Employer Name and Reason for Application
2) Employee First Name, Middle Initial, Last Name.
3) Employee Street Address
4) City
5) State
6) Zip Code
7) Employee Social Security Number
8) Effective Date of Coverage
9) Employee Status: Please check (✓) the appropriate box
indicating whether you are an Active, Retired, Hourly
or Salary employee. If retired, please indicate
retirement date.
10) 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.
11)
Employee Work Phone Number (including area code)
12) 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).
13) Check Type of Coverage for which you are enrolling,
using the appropriate category (employee, two person
or family).
14) T
o be completed by Account/Administrator only
Items 15 through 18 ask for important information about
yourself and each eligible member of your family (15
yourself, 16 your spouse/ domestic partner, 17-18 your
dependents). Please complete all requested information.
If relationship is “other”, please indicate the dependent’s
relationship to the employee according to the codes
provided on the application.
• First Name/Middle Initial/Last Name — Complete
the First Name, Middle Initial and Last Name for each
eligible person listed.
• Social Security Number — Please include the Social
Security Number of each person.
• 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”.
• Birth Date (month/day/year)
•Sex(female or male)
• 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.
Physician of Record (POR) Information — A Physician of
Record is the physician selected by the member, who
provides routine care and coordinates other specialized care.
Please note that choosing a POR does not impact your
benefits or claims payment in any way. Choosing a POR
simply helps us to better serve you by connecting you to the
practice where most of your health care is received.
a) Full Name of Physician of Record (POR) Group
Practice — Indicate the name of the POR Group
Practice selected from the Online Provider Directory for
yourself and each of your dependents. You and your
dependents can each choose a different POR.
b) Physician of Record (POR) Number from Provider
Directory — Please indicate the corresponding
number for the physician practice you or your
dependent chose as a POR from the Online Provider
Directory, Practice Information tab.
c) Are you an existing Patient of this POR? — Please
check “Yes” or “No” to indicate if you are currently a
patient of the POR you chose for yourself or your
dependents.
For online provider lookup, go to www.highmarkbcbs.com
and search under the “Find a Doctor or Rx” tab. If you need
assistance with choosing a POR, please call Member Service
at 1-800-241-5704.
Disclaimer: Please note that a provider number may not be
available for providers that are located outside of the local
servicing area. In this case, a POR cannot be chosen.
19) Needs to be completed if you, your spouse/domestic
partner or one of your eligible dependents has other
health insurance coverage or is eligible for Medicare.
Please complete all information requested. Refer to
your Medicare card to complete the Medicare
Information section.
20) Should be completed by your Account Administrator.
21) You must sign and date the form where indicated.
Once the form is completed, retain the last copy for your
records.
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.
EMPLOYEE INFORMATION — Employee must complete items 1 through 17 and sign.
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)
To be completed by Account Administrator only
Group Number Report Code Qualifier Report Code Value
*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
Authorized Employer Signature Date
20)
Employee Signature Date
21)
Membership Department
P.O. Box 535193
Pittsburgh, PA 15253-5193
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
Last First 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
1) Employer Name
2) Employee First Name / Middle Initial / Last Name
3) Street Address 4) City 5) State 6) Zip
7) Social Security Number
10) Employee Phone #—Home
( )
11) Employee Phone #—Work
( )
HIGHMARK BLUE CROSS BLUE SHIELD ENROLLMENT APPLICATION
8) Effective Date of Coverage
Month Day Year
9) Employee Status
❑ Active ❑ Hourly
❑ Retired (Date) ❑ Salary
Reason for Application ❑ Enrollment
❑ New Hire ❑ Rehire ❑ COBRA
❑ Act 4 ❑ Other:
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 Health Services 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 Health Services’ Notice of Privacy Practices is available on
Highmark Health Services’Web site, or from the Highmark Health Services Privacy Office.
12) Employee Hire Date
Month Day Year
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
14)
19)
JD-8 (12-15)
MARGINAL WORDS
Complete items 15 through 18 where applicable. List eligible participants. (If you have additional dependents, attach separate sheet.)
Self
Birth Date
Mo Dy Yr
Sex
F/M
Student
Benefits
Apply
Dis-
abled
Check If
Social Security Number
First Name / Middle Initial / Last Name
15)
16)
17)
18)
❑ Child
❑ Other*
❑ Child
❑ Other*
❑ Yes ❑ No
If YES, then
complete #24
Do you
have other
insurance?
❑ Yes ❑ No
If YES, then
complete #24
❑ Yes ❑ No
If YES, then
complete #24
❑ Yes ❑ No
If YES, then
complete #24
Act
4
a) Full Name of Physician of Record (POR) Group Practice b) POR Number from Provider Directory c) Are you an Established Patient? ❑ Yes ❑ No
a) Full Name of Physician of Record (POR) Group Practice b) POR Number from Provider Directory c) Is Spouse/DP an Established Patient? ❑ Yes ❑ No
a) Full Name of Physician of Record (POR) Group Practice b) POR Number from Provider Directory c) Is Dependent an Established Patient? ❑ Yes ❑ No
a) Full Name of Physician of Record (POR) Group Practice b) POR Number from Provider Directory c) Is Dependent an Established Patient? ❑ Yes ❑ No
❑ Spouse
❑ Dom. Part.*
Social Security Number
First Name / Middle Initial / Last Name
Social Security Number
First Name / Middle Initial / Last Name
Social Security Number
First Name / Middle Initial / Last Name
13) Check Type of Coverage MEDICAL DENTAL VISION DRUG PRODUCT NAME
Employee Only ❑❑❑❑ ❑
Insured & Spouse/Domestic Partner ❑❑❑❑ ❑
Family ❑❑❑❑ ❑
Parent & Child ❑❑❑❑ ❑
Parent & Children ❑❑❑❑ ❑
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Highmark PPO Enrollment Form Rev041416 Highmark BCBS 1c (Wilkes University)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 23 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document