Highmark Enrollment Form – Fill Out and Use This PDF

Effective Date

ENROLLMENT/WAIVER FORM

.

.(

Employer Name

Group Number

❑ENROLLING

❑WAIVING

Payroll Location

Name of Subscriber or Dependent

Health Insurance Claim Number

Medicare Supplement

or Complement?

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.

Highmark

Attn: Producer Affairs (SP 6E)

P.O. Box 890089

Camp Hill, PA 17089-0089

❑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

Question

number

Patient Name

Diagnosis

Date

Diagnosed

Type of

Treatment

Medications

Date of most recent

inpatient stay

Is ongoing treatment required?

If yes, please explain

/

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.