REASON FOR SUBMISSION (PLEASE CHECK ALL THAT APPLY)
ENROLLMENT
CHANGE TERMINATION
NEW HIRE CHANGE COVERAGE TYPE
VOLUNTARY CANCELLATION (SIGNATURE REQUIRED)
ANNUAL OPEN ENROLLMENT ADD DEPENDENT LISTED BELOW DECEASED DATE: __________________
PART TIME TO FULL TIME: ______________________ TERMINATE DEPENDENT LISTED BELOW
TRANSFER FROM GROUP #: ___________________
PO BOX 4090 - CONCORD, NH 03302
LOSS OF INSURANCE DATE: __________________________ NAME CHANGE - PREVIOUS NAME: _______________
(888) 960-6448 (P) (800) 229-6902 (F)
(ATTACH DOCUMENTS) MARRIAGE DATE: __________________
NEWBORN DATE: __________________
TO BE COMPLETED BY EMPLOYER:
DATE OF BIRTH
MO / DAY / YR
/ /
M
F
- -
Y N
/ /
M
F
- -
Y N
/ /
M
F
- -
Y N
/ /
M
F
- -
Y N
/ /
M
F
- -
Y N
/ /
M
F
- -
Y N
MEMBERS ARE ENCOURAGED TO OBTAIN THEIR PCP'S NUMBER BY VISITING HARVARD PILGRIM'S ONLINE PROVIDER DIRECTORY AT www.harvardpilgrim.org
SEND COMPLETED AND SIGNED FORMS TO YOUR EMPLOYER
STREET / PO BOX
FIRST MIDDLE LAST
HMO: _______ HMO-LP ELEVATEHEALTH POS PPO ME ME + PDP
NAMING CONVENTION/ GROUP NUMBER
MEMBERSHIP WILL BECOME EFFECTIVE UPON ACCEPTANCE BY THE PLAN. BENEFITS UNDER THE PLAN WILL BE EXPLAINED IN A SEPARATE DOCUMENT. FOR AN EXPLANATION OF HOW HARVARD PILGRIM MAY USE OR DISCLOSE YOUR PROTECTED HEALTH INFORMATION, PLEASE READ
YOUR NOTICE OF PRIVACY PRACTICES PROVIDED TO YOU BY HARVARD PILGRIM IN YOUR ENROLLMENT KIT. I UNDERSTAND THAT A COPY OF THIS FORM WILL BE GIVEN TO ME, OR MY AUTHORIZED REPRESENTATIVE, UPON REQUEST.
SOCIAL SECURITY NUMBER
AS AN HMO OR POS PLAN MEMBER YOU MUST CHOOSE A PRIMARY CARE PHYSICIAN (PCP) UPON ENROLLMENT
IF YOU DO NOT HAVE A PCP, NON-EMERGENCY AND MOST SPECIALTY CARE MAY NOT BE COVERED.
CURRENT PATIENT
OF THIS DOCTOR?
(HMO AND POS PLANS ONLY)
NAME AND TOWN FOR EACH MEMBER
01
RELATION
CODE
NHIT ENROLLMENT FORM (12/2017)
MEDICARE ENHANCE SUBSCRIBERS MUST PROVIDE A COPY OF THEIR MEDICARE PART A AND B CARD UPON ENROLLMENT.
WHAT LANGUAGE DO YOU SPEAK MOST OFTEN? THIS INFORMATION WILL HELP US WORK TOWARD BEST MEETING YOUR NEEDS. _______________________________________
IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES OR A DENIAL OF INSURANCE BENEFITS.
THE EMPLOYEE AND THE EMPLOYER MUST SIGN AND DATE THIS FORM FOR ENROLLMENT. H
(PLEASE CIRCLE)
FIRST MIDDLE LAST (IF NOT SAME AS EMPLOYEE)
MAILING ADDRESS
02 – SPOUSE 03 – CHILD UNDER 26 04 – DISABLED DEPENDENT (VERIFICATION REQUIRED)
CHILD DEPENDENTS ARE ELIGIBLE FOR COVERAGE THROUGH THE MONTH THAT THEY TURN 26
INDIVIDUAL TWO-PERSON FAMILY OTHER (ONLY WHERE OFFERED)
TO BE COMPLETED BY EMPLOYEE:
PLEASE USE THE CODES LISTED BELOW TO COMPLETE DEPENDENT RELATION BLOCK
TELEPHONE
( )
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