Fillable Nonpayroll Highmark Application (University of Delaware)

Fill Online, Printable, Fillable, Blank Nonpayroll Highmark Application (University of Delaware) Form

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

Nonpayroll Highmark Application (University of Delaware)

On average this form takes 20 minutes to complete

The Nonpayroll Highmark Application (University of Delaware) form is 2 pages long and contains:

  • 0 signatures
  • 53 check-boxes
  • 54 other fields

Country of origin: US
File type: PDF

U.S.A. forms for University of Delaware

BROWSE UNIVERSITY OF DELAWARE 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
 
STATE OF DELAWARE APPLICATION FOR COVERAGE
ENR-196 (R3-17)
Page 1 of 2
D. ELIGIBLE DEPENDENTS TO BE COVERED
FOR STATE OF DELAWARE USE ONLY
Name Phone Date Group Number Contact Dept./Agency
A. REASON FOR APPLICATION (CHECK ALL THAT APPLY). PLEASE PRINT LEGIBLY.
New coverage ADD DEPENDENTS DUE TO: CANCEL DEPENDENTS DUE TO: REINSTATE COVERAGE DUE TO:
Change coverage Marriage/Civil Union Non-voluntary coverage loss Divorce/Dissolution Death Rehire Administrative error
Information change Birth Other Over age Other Return from leave Other
Refuse coverage (see Section E) Adoption/Guardianship Date of event checked: No longer dependent Date of event checked: Return from layo Date of event checked:
B. PERSONAL INFORMATION
Male Retiree Non-employee Date of Hire/Retirement (month, day, year) Social Security Number Agency or School District
Female Surviving spouse
Last Name First Name M.I. Date of Birth (month, day, year) Home Phone (include area code) Business Phone (include area code)
Street Address City State Zip Code
C. HEALTH CARE COVERAGE CHOICES
COVERAGE IS FOR: Employee Employee & Spouse Employee & Child(ren) Family MEDICARE INFORMATION:
PLEASE MAKE ONE HEALTHCARE COVERAGE CHOICE: First State Basic Comprehensive PPO Applicant’s Medicare #: _______________________________________________________________
Special Medicll Special Medicll without prescription Part A Eective Date: ______________________________________________
I AM 65 OR OLDER. MY SPOUSE IS 65 OR OVER; I AM A FULLTIME EMPLOYEE. Part B Eective Date: _____________________________________________
If more space is needed to list dependents, please use a separate sheet of paper and attach it to this application.
Add Spouse’s First Name M.I. Last Name (if dierent), Jr., Sr. Birth Date (month, day, year) Spouse’s Social Security Number
Cancel
Add Dependent’s First Name M.I. Last Name (if dierent), Jr., Sr. Birth Date (month, day, year) Dependent’s Social Security Number
Cancel Fulltime student Male
Handicapped Female
Add Dependent’s First Name M.I. Last Name (if dierent), Jr., Sr. Birth Date (month, day, year) Dependent’s Social Security Number
Cancel Fulltime student Male
Handicapped Female
Add Dependent’s First Name M.I. Last Name (if dierent), Jr., Sr. Birth Date (month, day, year) Dependent’s Social Security Number
Cancel Fulltime student Male
Handicapped Female
I understand that: 1) Rights to service are subject to acceptance of this application and to the terms and conditions
specied in the present contract and any future contract between my employer, association and Highmark Blue
Cross Blue Shield Delaware (Highmark DE). 2) I certify that all representations and information supplied by me are
true. My coverage shall be void if any or part of this application is false or incomplete. 3) I authorize my employer,
as my agent, if applicable to collect the premiums by payroll deduction or otherwise, for remittance to Highmark
DE, with the understanding that payment will not be complete until actually received. 4) I, on behalf of myself and
my covered dependents, authorize any physician, hospital or any other health care provider to release information
available to them concerning any diagnosis, treatment or other health care services they render to me or my
covered dependents to Highmark DE or its designee for purposes reasonably related to this contract. 5) I, on behalf
of myself and my covered dependents, authorize Highmark DE to release appropriate demographic information,
diagnostic and medical conditions to other persons, entities or organizations for audits, claims processing,
coordination of benets, disease management programs, member satisfaction surveys, other party liability,
utilization review, case management, quality improvement and assurance and other reasonably related purposes
for the administration of this contract or as required by law. 6) If covering a spouse, you must go online at and
complete a Coordination of Benets form.
Page 2 of 2
Highmark Blue Cross Blue Shield Delaware is an independent licensee of the Blue Cross and Blue Shield Association
E. OTHER COVERAGE INFORMATION
Anyone covered by other health insurance? If YES, and the coverage is through an employer, list name of employer below: Name and Location of Other Insurance Company Transferring your coverage from another Highmark
I am My spouse My dependent child(ren) DE contract? Y N
F. TERMS OF AGREEMENT
I elect not to participate in the State Health Insurance Program. I have read and do agree to the above terms. Date
Signature: Signature:
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not
discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/
Insurer does not exclude people or treat them differently because of race, color, national origin, age,
disability, or sex. The Claims Administrator/Insurer:
• Provides free aids and services to people with disabilities to communicate effectively with us, such as:
– Qualified sign language interpreters
– Written information in other formats (large print, audio, accessible electronic formats, other formats)
• Provides free language services to people whose primary language is not English, such as:
– Qualified interpreters
– Information written in other languages
If you need these services, contact the Civil Rights Coordinator.
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated
in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance
with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711,
Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or
by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for
Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company,
Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company,
First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions
Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and
Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.
U65_DE_G_M_1Col_12pt_blk_4c
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not
discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/
Insurer does not exclude people or treat them differently because of race, color, national origin, age,
disability, or sex. The Claims Administrator/Insurer:
• Provides free aids and services to people with disabilities to communicate effectively with us, such as:
– Qualified sign language interpreters
– Written information in other formats (large print, audio, accessible electronic formats, other formats)
• Provides free language services to people whose primary language is not English, such as:
– Qualified interpreters
– Information written in other languages
If you need these services, contact the Civil Rights Coordinator.
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated
in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance
with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711,
Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or
by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for
Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company,
Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company,
First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions
Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and
Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.
U65_DE_G_M_1Col_12pt_blk_4c
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not
discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/
Insurer does not exclude people or treat them differently because of race, color, national origin, age,
disability, or sex. The Claims Administrator/Insurer:
• Provides free aids and services to people with disabilities to communicate effectively with us, such as:
– Qualified sign language interpreters
– Written information in other formats (large print, audio, accessible electronic formats, other formats)
• Provides free language services to people whose primary language is not English, such as:
– Qualified interpreters
– Information written in other languages
If you need these services, contact the Civil Rights Coordinator.
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated
in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance
with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711,
Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or
by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for
Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company,
Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company,
First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions
Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and
Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.
U65_DE_G_M_1Col_12pt_blk_4c
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

Nonpayroll Highmark Application (University of Delaware)

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 2 February 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document