Highmark Enrollment Waiver Application Details

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.

QuestionAnswer
Form NameHighmark Enrollment Form
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other nameshighmark bcbs enrollment form, highmark west virginia waiver of appeal form, highmark enrollment waiver form, highmark enrollment form

Form Preview Example

Effective Date

ENROLLMENT/WAIVER FORM

.

.(

Employer Name

Group Number

ENROLLING

WAIVING

Payroll Location

Last Name

 

 

 

 

 

 

First Name

 

 

 

 

 

MI

 

Social Security No.

 

 

Marital Status

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Please check one):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

Email Address

 

 

 

 

 

 

 

Single/Widowed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Married

 

City

 

 

 

State

 

Zip

 

 

 

 

Home Phone

 

Work Phone

 

 

Divorced

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employment Status

 

Date of Full-Time Hire

Hours Worked

COBRA

 

 

 

 

COBRA REASON:

 

 

 

 

 

 

 

 

 

 

 

 

Mo

 

Day

 

Yr

Per

 

 

Start Date ___________________

Deceased Involuntary Lay-Off Date of Event _________________

Active COBRA Disabled

 

 

 

 

 

 

Week

 

 

End Date

___________________

Left Employment Other ___________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Covered Dependents

 

First Name & Middle Initial (show Last

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dependent Status

 

 

 

 

 

and Relationship

 

Name if different from Subscriber)

 

 

Social Security #

 

Birthdate

 

Sex

Height

Weight

If Over Age 26

 

Med

Vis

 

Den

Self

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

 

/

 

M

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

F

 

 

 

 

 

 

 

 

Spouse

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

 

/

 

M

 

 

 

 

 

 

 

 

Dom. Part.*

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Child

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

 

/

 

M

 

 

Disabled

 

 

 

 

 

Other*

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Child

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

 

/

 

M

 

 

Disabled

 

 

 

 

 

Other*

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Child

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

 

/

 

M

 

 

Disabled

 

 

 

 

 

Other*

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*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

 

 

MEDICAL

VISION

DENTAL

 

 

 

 

 

I HEREBY DECLINE MEDICAL COVERAGE:

REASON FOR DECLINING MEDICAL COVERAGE:

I HEREBY DECLINE VISION COVERAGE:

I HEREBY DECLINE DENTAL COVERAGE:

 

For myself

 

For myself

For myself

 

For family members ONLY

Insured under spouse’s contract with the following insurance carrier:

For family members ONLY

For family members ONLY

 

For myself and ALL family members

_______________________________________________________

For myself and ALL family members

For myself and ALL family members

 

For the following person(s):

Other: __________________________________________________

For the following person(s):

For the following person(s):

________________________________

 

____________________________________

__________________________________

 

 

 

 

 

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

 

ONLY SIGN IF YOU ARE WAIVING COVERAGE

 

 

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

ENR-129 (R4-12)

Other Group or Non-Group Health Insurance Coverage

Name of Insurance Carrier

 

Group Number

Effective Date

 

Name of Policy Holder

 

 

 

 

 

/

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Policy Holder Date of Birth

 

Relationship to Policyholder

Policy Number

 

 

Policyholder Employment Status

 

 

/

/

 

 

 

 

Active

Retired - List Date of Retirement:

/

/

 

 

 

 

 

 

 

 

 

 

Medicare Coverage (Please list any family member that is eligible for Medicare Benefits)

Name of Subscriber or Dependent

Health Insurance Claim Number

 

Effective Dates

 

Check () Reason For Medicare Coverage

 

 

 

 

 

 

Hospital (Part A)

Medical (Part B)

Prescription (Part D)

Age

Disability

End Stage Renal Disease

Medicare Supplement

or Complement?

Yes

No

 

 

Yes

No

 

 

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.

 

 

 

 

 

Authorized Employer Signature

 

Date

 

 

 

 

 

Print Company Name

 

 

 

 

 

 

 

 

 

 

 

 

 

Employee Signature

 

Date

 

 

 

 

 

Print Employee’s Name

 

 

 

Highmark

Attn: Producer Affairs (SP 6E)

P.O. Box 890089

Camp Hill, PA 17089-0089

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 -27. Attach additional sheets if necessary.

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

 

 

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.

Employee

Print

 

Signature:

Employee Name:

Date:

 

 

 

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