Pilgrim Enrollment Form PDF Details

Enrolling your children or yourself in a pilgrimage can be an exciting and rewarding experience. It is important to make sure that everyone involved has access to the forms and information necessary to participate as safely and effectively as possible. That’s why we have compiled all of the relevant enrollment forms into one easy-to-use source – right here on this blog! With just a few clicks, you can ensure that your travel plans are correctly recorded so that everybody embarking on the journey has correct information regarding dates, destinations, activity guidelines, and more. Read on for details about how you can fill out a Pilgrim Enrollment Form today!

QuestionAnswer
Form NamePilgrim Enrollment Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namespilgrim change form, harvard pilgrim prior authorization form, harvard pilgrim medicare prior authorization form, hmo enrollment form

Form Preview Example

The Harvard Pilgrim HMO

REASON FOR SUBMISSION (Please check all that apply)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ENROLLMENT

 

 

 

CHANGE

 

 

 

 

 

 

 

 

 

 

TERMINATION

 

 

 

Enrollment/Change Form

NEW HIRE

(ATTACH DOCUMENTS)

CHANGE COVERAGE TYPE

NAME/ADDRESS CHANGE

LEFT EMPLOYMENT

NO LONGER ELIGIBLE

 

 

 

 

 

 

 

 

 

 

 

 

LOSS OF INSURANCE

 

 

 

 

 

 

 

 

 

 

 

 

ANNUAL OPEN ENROLLMENT

 

 

 

ADD DEPENDENT LISTED BELOW

LOSS OF INSURANCE

VOLUNTARY CANCELLATION

DECEASED DATE

 

 

PO BOX 9185 • QUINCY, MA 02269

COBRA

 

 

 

TERMINATE DEPENDENT

 

(ATTACH DOCUMENTS)

MOVED FROM SERVICE AREA

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1-888-333-HPHC

P/T TO F/T DATE

 

 

 

 

LISTED BELOW

 

 

 

 

MARRIAGE DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OTHER

 

 

 

OTHER

 

 

 

 

 

 

 

 

 

 

OTHER

 

 

 

 

 

 

 

 

www.harvardpilgrim.org

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONTRACT / ID NUMBER

 

 

GROUP / COMPANY NAME

 

 

 

 

 

 

DATE OF HIRE

 

 

 

 

 

 

DIVISION

 

 

 

 

 

 

 

EFFECTIVE DATE

H

 

P

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMPLOYEE NAME

 

 

 

 

 

 

 

 

 

TYPE OF COVERAGE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FIRST

MIDDLE

LAST

 

 

 

INDIVIDUAL

2-PERSON (Only where offered)

 

 

MARITAL STATUS

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS

 

 

 

 

 

 

 

 

 

FAMILY

OTHER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

APT. NO.

STREET

 

PO BOX

PLEASE USE THE CODES LISTED BELOW TO COMPLETE DEPENDENT RELATION BLOCK

 

 

 

 

COUNTY

02 SPOUSE

03 UNMARRIED CHILD UNDER 19

04

UNMARRIED STEPCHILD UNDER 19

 

 

 

 

 

 

CITY

 

STATE

ZIP

05 * UNMARRIED FULL-TIME STUDENT OVER AGE19

06

HANDICAPPED (VERIFICATION REQUIRED)

07 EX-SPOUSE

TELEPHONE (HOME)

TELEPHONE (WORK)

IT IS VERY IMPORTANT THAT EACH MEMBER SELECT A PRIMARY CARE PHYSICIAN.

(

)

(

)

AS A PLAN MEMBER YOU MUST CHOOSE A PRIMARY CARE PHYSICIAN (PCP). IF YOU DO NOT HAVE A PCP, NON-EMERGENCY AND

 

MOST SPECIALITY CARE MAY NOT BE COVERED.

 

 

 

 

 

 

 

 

 

 

DATE OF BIRTH

 

 

 

 

 

 

 

 

 

 

ARE YOU

 

 

LANGUAGE

 

 

SEX

RELATION

SOCIAL SECURITY NUMBER

SELECT A PRIMARY CARE PHYSICIAN AND

A REGULAR

PCP #

 

MO

 

 

DAY

YR

 

PATIENT OF

FIRST MI LAST (IF NOT SAME AS EMPLOYEE)

CODE

 

 

CODE

TOWN FOR EACH MEMBER

 

 

 

 

 

 

 

 

 

THIS DOCTOR?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMPLOYEE

 

 

 

 

 

 

 

 

M

F

O1

 

 

 

 

 

 

Y

N

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SPOUSE

 

 

 

 

 

 

 

 

M

F

 

 

 

 

 

 

 

Y

N

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DEPENDENT

 

 

 

 

 

 

 

 

M

F

 

 

 

 

 

 

 

Y

N

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DEPENDENT

 

 

 

 

 

 

 

 

M

F

 

 

 

 

 

 

 

Y

N

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DEPENDENT

 

 

 

 

 

 

 

 

M

F

 

 

 

 

 

 

 

Y

N

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DEPENDENT

 

 

 

 

 

 

 

 

M

F

 

 

 

 

 

 

 

Y

N

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LANGUAGE

CODES

(Optional)

WHAT LANGUAGE DO YOU SPEAK MOST OFTEN? PLEASE LIST THE APPROPRIATE CODE AFTER EACH MEMBER’S NAME. THIS INFORMATION WILL HELP US WORK TOWARD BEST MEETING YOUR NEEDS.

 

AS

 

CA

 

 

CV

 

EN

 

FR

 

HA

 

HM

 

IT

 

KH

 

LO

 

 

MN

 

 

PT

 

 

RU

 

 

SP

 

 

VI

 

OTHER

 

American

Sign

Language

Cantonese

 

Cape Verdean

English

French

Haitian

Hmong

Italian

Khmer

Laotian

Mandarin

Portuguese

Russian

Spanish

Vietnamese

 

Specify

*IF YOU HAVE LISTED A FULL-TIME STUDENT(S) OVER AGE 19 BUT UNDER THE MAXIMUM STUDENT AGE, SUPPLY THE FOLLOWING INFORMATION:

STUDENT(S) NAME

NAME OF SCHOOL(S)

 

 

 

 

 

 

 

 

 

THIS INFORMATION MAY BE USED TO VERIFY ELIGIBILITY

HAVE YOU EVER BEEN A MEMBER OF Pilgrim Health Care, Harvard Community Health Plan, HCHP OF NE, HPHC OR HPHC OF NE? YES

NO

IF YOU WOULD LIKE TO RECEIVE A MENU OF ELECTRONIC WAYS TO INTERACT WITH US, LIST YOUR E-MAIL ADDRESS HERE.

 

E-MAIL ADDRESS:

 

(OPTIONAL)

 

THE E-MAIL MENU YOU RECEIVE MAY INCLUDE CHOICES SUCH AS; SECURE E-MAIL WITH YOUR PHYSICIAN, REPLACEMENT OF HPHC MAILINGS WITH E-MAILS POINTING TO OUR WEB-SITES, HEALTH-RELATED UPDATES AND REMINDERS, AND OTHER POSSIBLE OPTIONS. CONFIDENTIAL E-MAIL WILL BE SENT THROUGH A SECURE WEB-SITE, AND YOU WILL RECEIVE NOTIFICATION THAT THERE IS A MESSAGE FOR YOU AT THE SITE. NON-CONFIDENTIAL UPDATES AND REMINDERS YOU ELECT TO RECEIVE WILL BE SENT DIRECTLY TO THE E-MAIL ADDRESS LISTED ABOVE.

YOUR E-MAIL ADDRESS WILL BE STORED IN A PROTECTED DATABASE AND WILL REMAIN CONFIDENTIAL.

I UNDERSTAND THAT MEMBERSHIP WILL BECOME EFFECTIVE UPON ACCEPTANCE BY THE PLAN AND THAT BENEFITS UNDER THE PLAN WILL BE EXPLAINED IN A SEPARATE DOCUMENT. I ALSO UNDERSTAND THAT THE SUBROGATION PROVISION APPLICABLE TO MAINE MEMBERS, OUTLINED IN A SEPARATE DOCUMENT, PERMITS SUBROGATION PAYMENTS ON A JUST AND EQUITABLE BASIS. DURING MY MEMBERSHIP, I AUTHORIZE ANY HEALTH CARE PROVIDER OR OTHER HEALTH PLAN TO PROVIDE MEDICAL INFORMATION AND RECORDS TO THE PLAN, THE PLAN ADMINISTRATOR, OR PLAN AFFILIATED HEALTH CARE PROVIDERS. I ALSO AUTHORIZE THE PLAN, THE PLAN ADMINISTRATION, AND ANY PLAN HEALTH CARE PROVIDERS RENDERING SERVICES TO ME OR MY DEPENDENTS TO RECEIVE COPIES OF MY OR MY DEPENDENTS’ MEDICAL RECORDS. I AUTHORIZE THE USE BY THE PLAN, AND ITS AGENTS, OF ANY INFORMATION OBTAINED HEREUNDER FOR THE DELIVERY OF HEALTH SERVICE, TO DETERMINE ELIGIBILITY AND ENTITLEMENT TO BENEFITS (INCLUDING REIMBURSEMENT BY THIRD PARTIES), FOR EDUCATION AND RESEARCH IN ACCORDANCE WITH GOVERNMENT REGULATIONS, AND FOR THE OTHER PLAN PROFESSIONAL ACTIVITIES SUCH AS UTILIZATION REVIEW, QUALITY ASSURANCE, CASE MANAGEMENT, REFERRAL AND AUTHORIZATION,DISEASE MANAGEMENT, FRAUD DETECTION AND CERTAIN OVERSIGHT ACTIVITIES, SUCH AS ACCREDITATION AND REGULATORY AUDITS. I UNDERSTAND THAT A COPY OF THIS FORM WILL BE GIVEN TO ME, OR TO MY AUTHORIZED REPRESENTATIVE, UPON REQUEST.

NEW HAMPSHIRE BASED GROUPS PLEASE NOTE: THE ENROLLED PARTICIPANT SHALL BE ALLOWED A GRACE PERIOD OF TEN (10) DAYS FOR MAKING ANY PAYMENT DUE UNDER CONTRACT (RSA 420-B:8,IV(b)).

It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.

THE EMPLOYEE, SPOUSE AND ALL DEPENDENTS AGE 18 YEARS AND OVER MUST SIGN THIS FORM FOR ENROLLMENT.

EMPLOYEE SIGNATURE

 

DATE

 

DEPENDENT SIGNATURE (age 18 years - over)

 

DATE

 

DEPENDENT SIGNATURE (age 18 years - over)

 

DATE

 

 

 

 

 

 

 

 

 

 

 

SPOUSE SIGNATURE (if applicable)

 

DATE

 

DEPENDENT SIGNATURE (age 18 years - over)

 

DATE

 

EMPLOYER SIGNATURE

 

DATE

10/01 001-11 HPG

WHITE - HARVARD PILGRIM COPY

YELLOW - EMPLOYER COPY

PINK - EMPLOYEE COPY

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