Page 46 - Tampa Bay Rays 2022 Flipbook

Membership Department P.O. Box 535193 Pittsburgh, PA 15253-5193 PRODUCT NAME 100/80 80/60 70% q q q q q Check If Student Act Dis- Benefits 4 abled Apply Part D Effective Date (Mo-Day-Yr) / / / / / / JD-7 (R11-16)

DRUG q q q q q Report Code Value Sex F/M Yr c) Are you an Established Patient? qYes qNo c) Is Spouse/DP an Established Patient? qYes qNo c) Is Dependent an Established Patient? qYes qNo c) Is Dependent an Established Patient? qYes qNo Date
VISION q q q q q Birth Date Dy Part B Effective Date (Mo-Day-Yr) / / / / / /

Mo
DENTAL q q q q q Report Code Qualifier Do you have other insurance? qYes qNo If YES, then complete #19 qYes qNo If YES, then complete #19 qYes qNo If YES, then complete #19 qYes qNo If YES, then complete #19

MEDICAL q q q q q To be completed by Account Administrator only Part A Effective Date (Mo-Day-Yr) / / / / / / 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 H

13) Check Type of Coverage Employee Only Insured & Spouse/Domestic Partner Family Parent & Child Parent & Children Group Number Social Security Number Social Security Number Social Security Number Social Security Number Health Insurance Claim Number q End Stage Renal Disease qNo qYes

qHourly 14) qSalary

qEnrollment qCOBRA 6) Zip Year b) POR Number from Provider Directory b) POR Number from Provider Directory b) POR Number from Provider Directory b) POR Number from Provider Directory q Disability Employee Signature

5) State Day MEDICARE INFORMATION: List any family member that is eligible for Medicare Benefits: q Age 21) Highmark Blue Cross Blue Shield is an independent licensee of the Blue Cross and Blue Shield Association
qRehire
Other:
Reason for Application qNew Hire q qAct 4 9) Employee Status qActive qRetired (Date) 12) Employee Hire Date Month First Do you have a Medicare Supplement or other coverage that complements Medicare?

HIGHMARK BLUE CROSS BLUE SHIELD ENROLLMENT APPLICATION

Year *If “domestic partner” or “other” applies, complete using one of the following codes: (05) Grandchild, (07) Nephew or Niece, (17) Stepson or Stepdaughter, (29) Domestic Partner Name of Member Why are you eligible for Medicare? Date
4) City First Name / Middle Initial / Last Name First Name / Middle Initial / Last Name First Name / Middle Initial / Last Name First Name / Middle Initial / Last Name Last
EMPLOYEE INFORMATION — Employee must complete items 1 through 17 and sign.

8) Effective Date of Coverage Day Month 11) Employee Phone #—Work ( ) Complete items 15 through 18 where applicable. List eligible participants. (If you have additional dependents, attach separate sheet.) Effective Date: (Date) q Active q Retired 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 ap

2) Employee First Name / Middle Initial / Last Name a) Full Name of Physician of Record (POR) Group Practice a) Full Name of Physician of Record (POR) Group Practice a) Full Name of Physician of Record (POR) Group Practice a) Full Name of Physician of Record (POR) Group Practice If you checked YES to other insurance, fill in appropriate line: Relationship to Highmark Policy Holder: Policy Holder Date of Birth: Policy Holder Employment Status: Authorized Employer

1) Employer Name 3) Street Address 7) Social Security Number 10) Employee Phone #—Home ( ) Self qSpouse qDom. Part.* qChild qOther* qChild qOther* Name of Insurance Carrier: Group No: Name of Policy Holder: Policy Number:

46 15) 16) 17) 18) 19) 20)