Highmark Enrollment Form ≡ Fill Out Printable PDF Forms Online

Question	Answer
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

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Effective Date

ENROLLMENT/WAIVER FORM

Employer Name

Group Number

❑ENROLLING

❑WAIVING

Payroll Location

Last Name

First Name

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:

Day

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: ________________________________________________________________

		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 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.

Employee	Print
Signature:	Employee Name:	Date:

Highmark Enrollment Form – Fill Out and Use

Highmark Enrollment Waiver Application Details

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Highmark Enrollment Form – Fill Out and Use

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