Welcome to the Highmark enrollment form! In order to become a Highmark member, you will need to complete this form and return it to us. The process is simple, and we will be with you every step of the way.
You can find information regarding the type of form you need to prepare in the table. It can tell you the time it should take to finish highmark enrollment form, what parts you will have to fill in, and so forth.
Question | Answer |
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Form Name | Highmark Enrollment Form |
Form Length | 3 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 45 sec |
Other names | highmark bcbs enrollment form, highmark west virginia waiver of appeal form, highmark enrollment waiver form, highmark enrollment form |
Effective Date
ENROLLMENT/WAIVER FORM
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Employer Name
Group Number
❑ENROLLING
❑WAIVING
Payroll Location
Last Name |
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First Name |
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MI |
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Social Security No. |
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Marital Status |
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(Please check one): |
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Address |
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Email Address |
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❑ Single/Widowed |
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❑ Married |
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City |
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State |
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Zip |
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Home Phone |
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Work Phone |
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❑ Divorced |
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Employment Status |
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Date of |
Hours Worked |
❑ COBRA |
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COBRA REASON: |
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Yr |
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Start Date ___________________ |
❑ Deceased ❑ Involuntary |
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❑ Active ❑ COBRA ❑ Disabled |
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Week |
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End Date |
___________________ |
❑ Left Employment ❑ Other ___________________________________ |
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Covered Dependents |
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First Name & Middle Initial (show Last |
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Dependent Status |
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and Relationship |
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Name if different from Subscriber) |
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Social Security # |
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Birthdate |
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Sex |
Height |
Weight |
If Over Age 26 |
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Med |
Vis |
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Den |
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Self |
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❑M |
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❑F |
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❑ Spouse |
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❑M |
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❑ Dom. Part.* |
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❑F |
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❑ Child |
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/ |
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❑M |
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❑ Disabled |
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❑ Other* |
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❑F |
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❑ Child |
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/ |
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❑M |
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❑ Disabled |
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❑ Other* |
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❑F |
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❑ Child |
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/ |
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❑M |
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❑ Disabled |
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❑ Other* |
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❑F |
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*If “domestic partner” or “other” applies, complete using one of the following codes: (02) Adopted Child, (05) Grandchild, (07) Nephew or Niece, (17) Stepson or Stepdaughter and (29) Domestic Partner. Legal Documentation (Court Decree, Guardianship Papers, etc.) must be
attached to this Application if relationship: ❑ Other: ________________________________________________________________
(t
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MEDICAL |
VISION |
DENTAL |
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I HEREBY DECLINE MEDICAL COVERAGE: |
REASON FOR DECLINING MEDICAL COVERAGE: |
I HEREBY DECLINE VISION COVERAGE: |
I HEREBY DECLINE DENTAL COVERAGE: |
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❑For myself |
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❑For myself |
❑ For myself |
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❑For family members ONLY |
❑Insured under spouse’s contract with the following insurance carrier: |
❑For family members ONLY |
❑ For family members ONLY |
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❑ For myself and ALL family members |
_______________________________________________________ |
❑For myself and ALL family members |
❑ For myself and ALL family members |
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❑For the following person(s): |
❑ Other: __________________________________________________ |
❑For the following person(s): |
❑ For the following person(s): |
________________________________ |
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____________________________________ |
__________________________________ |
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I hereby certify that I have been given the opportunity to participate in the group insurance plan provided by my employer. If I and/or any of my Eligible Dependents desire to apply for this insurance at a later date, I may be required to wait until my group’s renewal or until a qualifying event occurs before coverage will be offered.
Employee Signature |
Date |
Employer Signature |
Date |
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ONLY SIGN IF YOU ARE WAIVING COVERAGE |
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If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance coverage, you may in the future be able to enroll yourself or your dependents in this plan, provided that you request enrollment within 30 days after your other coverage ends, or not later than 60 days if the other plan coverage was through Medicaid or a state Children’s Health Insurance Program (CHIP). In addition, as long as you are covered by the group’s health insurance plan provided by your employer, if you have a new dependent as a result of marriage, birth, adoption or placement for adoption, you may be able to enroll yourself and your dependents, provided that you request enrollment within 30 days after the marriage, birth, adoption or placement for adoption.
BOTH EMPLOYEE AND EMPLOYER SIGNATURES ARE REQUIRED FOR WAIVERS
Highmark Health Insurance Company is an independent licensee of the Blue Cross and Blue Shield Association |
Other Group or
Name of Insurance Carrier |
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Group Number |
Effective Date |
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Name of Policy Holder |
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Policy Holder Date of Birth |
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Relationship to Policyholder |
Policy Number |
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Policyholder Employment Status |
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❑Active |
❑Retired - List Date of Retirement: |
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Medicare Coverage (Please list any family member that is eligible for Medicare Benefits)
Name of Subscriber or Dependent
Health Insurance Claim Number
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Effective Dates |
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Check (✓) Reason For Medicare Coverage |
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Hospital (Part A) |
Medical (Part B) |
Prescription (Part D) |
Age |
Disability |
End Stage Renal Disease |
Medicare Supplement
or Complement?
❑Yes |
❑No |
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❑Yes |
❑No |
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❑Yes |
❑No |
I understand that this form enrolls those eligible persons listed above in the Products as described in the agreement between the plan and my employer. I authorize any payroll deductions required for the coverage and recognize that I must formally enroll my dependents on this form or they will not be covered.
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.
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Authorized Employer Signature |
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Date |
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Print Company Name |
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Employee Signature |
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Print Employee’s Name |
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Highmark
Attn: Producer Affairs (SP 6E)
P.O. Box 890089
Camp Hill, PA
Please answer each question below as completely as possible. NOTE: Medical information disclosed in this section will not be used to determine the eligibility of you and/or your dependents to enroll in the coverage requested. If you or any of your dependents have any of the conditions listed below, please check all numbers and circle the specific condition(s) that apply.
Then, in the Explanation section below, please give details for all diagnosis circled in questions 1
❑1. Cancer, Leukemia, Tumor or Cyst
❑2. Heart Surgery (Angioplasty, Stent or Bypass), Heart Disease, Implanted Pace Maker or Defibrillator, Irregular Heartbeat, Heart Murmur, Heart Regurgitation, Chest Pain, Congestive Heart Failure or Mitral Valve Prolapse
❑3. Vasculitis or Peripheral Vascular Disease
❑4. High Blood Pressure, and/or High Cholesterol
❑5. Emphysema, COPD, Cystic Fibrosis, Asthma or Allergies
❑6. Sleep Apnea, or Disease of the Throat, Ears, Nose, Sinuses or Eyes (except glasses)
❑7. Ulcerative Colitis, Crohn’s, Diverticulitis, Stomach Ulcers, Acid Reflux, GERD, Hernia, Gallbladder or Rectal Disorders
❑8. Diabetes Type I or II
❑9. Hypothyroid, Hyperthyroid, Goiter, Pituitary, Pancreas or Glandular Disorders or Disorders requiring Growth Hormones
❑10. Hepatitis (please circle type): A, B, C, or Autoimmune Hepatitis
❑11. Bladder, Kidney, Prostate, Testicular, Uterine, Kidney Failure or Dialysis, Abnormal PAP in the last 5 years or Breast Condition
❑12. Any female to be covered currently Pregnant? Due Date _________________. If yes, how many fetuses (single, twins, triplets, etc.). If pregnant, please give details including any complications
❑13. Arthritis (Osteo, Rheumatoid or Other), Joint Replacement, Joint Pain, Lupus, Fibromyalgia, Fractures or Limb Loss
❑14. Neck or Back Pain, Disorders of the Spine or Disc Herniation/Bulging
❑15. Head or Spinal Injuries, Muscular Dystrophy, Cerebral Palsy, or Multiple Sclerosis
❑16. Any blood disorder such as Anemia or Hemophilia
❑17. Aneurysm (Aortic or Cerebral), Blood Clot, TIA or Stroke
❑18. AIDS, HIV, Chronic Fatigue Syndrome, any Immune Suppressed Illness
❑19. Depression, Anxiety, ADD, ADHD, Psychotic Disorder
❑20. Any Drug or Alcohol Problems
❑21. Any Stem Cell or Organ Transplant (planned, recommended or already performed)
❑22. Cigarette or Tobacco use?
❑23. Any hospitalizations in the last 5 years (Please give full details below)
❑24. Any future surgeries discussed, planned or recommended (Please give full details below)
❑25. Currently taking any prescription medications? Please give details below to include the name of the medication and condition for which the medication is needed.
❑26. Are there any other medical conditions not listed above? (Please give full details below)
❑27. In the last five years have you been treated (including medication) for, diagnosed with, or sought treatment from a member of the medical profession for : Macular Degeneration,
Retinitis Pigmentosa, Retinopathy? ❑Yes ❑ No
Provide an explanation for each box marked in questions 1 - 27. Any prescription medications that are not in response to the questions above - please list prescription medication and the reason for the medication. If additional space is needed, please attach additional sheets. When completing the application, please DO NOT INCLUDE any genetic information such as family medical history or any information related to genetic testing, genetic services, genetic counseling or genetic diseases for which you believe that you or your dependent(s) may be at risk.
Question
number
Patient Name
Diagnosis
Date
Diagnosed
Type of
Treatment
Medications
Date of most recent
inpatient stay
From |
To |
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Is ongoing treatment required?
If yes, please explain
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I understand that this form enrolls those eligible persons listed above in the Products as described in the agreement between the plan and my employer. I authorize any payroll deductions required for the 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 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. I further acknowledge and
agree that Highmark may disclose enrollment, disenrollment summary health and/or premium billing information requested by the POR (Producer of Record) for purposes of inputting, updating and/or reviewing the same for the above identified business.
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.
Employee |
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Signature: |
Employee Name: |
Date: |
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