Loading
Get Member Application And Change Form - Upmc Health Plan
How it works
-
Open form follow the instructions
-
Easily sign the form with your finger
-
Send filled & signed form or save
How to use or fill out the Member Application And Change Form - UPMC Health Plan online
Filling out the Member Application and Change Form for UPMC Health Plan online can be straightforward with the right guidance. This document allows users to either enroll in a new health plan or make changes if they are already a member.
Follow the steps to successfully complete your application online.
- Click the ‘Get Form’ button to access the Member Application and Change Form. This will allow you to open the form in an editing interface.
- Begin by selecting a plan based on what is offered by your employer. Choose only one medical plan from the options available.
- Indicate your reason for application. Select 'Open Enrollment' if you are applying during your company’s designated period. Choose another applicable option if necessary.
- For current members making changes, fill out the 'Change of Status/Coverage' section to reflect any necessary adjustments to your dependents or personal information.
- Specify who will be covered under the selected plan. Carefully choose the medical, dental, and vision coverage options that suit your needs.
- Provide your employee information, including your name, address, and employment date. Contact your HR department if you need assistance with your employment start date.
- List the details of yourself and any dependents you want to cover. Include their full names, social security numbers, dates of birth, and other required information. If listing more than three dependents, use an additional form.
- Complete the 'Other Group Health Insurance' section if you or any dependents have additional health coverage. Provide the necessary names and details, and attach a separate sheet if required.
- Sign and date the application form at the end. It is important to keep a copy of your completed application for your records.
Complete your Member Application and Change Form online today!
You can obtain your UPMC member ID by logging into your member account on the UPMC Health Plan website. Your member ID will be available in your account details, or you can request it through customer service. If you are new to UPMC, the Member Application And Change Form - UPMC Health Plan will provide your ID after your application is processed.
Industry-leading security and compliance
US Legal Forms protects your data by complying with industry-specific security standards.
-
In businnes since 199725+ years providing professional legal documents.
-
Accredited businessGuarantees that a business meets BBB accreditation standards in the US and Canada.
-
Secured by BraintreeValidated Level 1 PCI DSS compliant payment gateway that accepts most major credit and debit card brands from across the globe.