Get Member Responsibility

This guide provides detailed instructions on how to complete the MEMBER RESPONSIBILITY form online. Following these steps will ensure that you accurately fill out all necessary sections and understand your responsibilities under the plan.

Follow the steps to complete the MEMBER RESPONSIBILITY form effectively.

1. Click the ‘Get Form’ button to access the MEMBER RESPONSIBILITY form. This will allow you to open the document in your preferred online editor.
2. Begin by entering your personal information in the designated fields. This typically includes your name, address, and contact information. Ensure all details are accurate, as this assists in processing your form correctly.
3. Review the Annual Deductible section. Indicate your chosen deductible amounts for both individual and family categories. Ensure you understand the implications of these choices on your out-of-pocket costs.
4. Proceed to the Out-of-Pocket Maximum section. Here, you will need to confirm the maximum amount you are willing to pay out-of-pocket for covered services. Familiarize yourself with the differences between participating and non-participating providers.
5. Next, fill out the Outpatient Services section. This includes detailing copays for various services, such as physician visits and preventive services. Make sure to check which services do not require a deductible.
6. Continue to the Hospital Services section and enter the necessary information regarding hospital care, physician fees, and other related services. Understand how these costs apply post-deductible.
7. Fill out the Maternity Services and Family Planning sections, if applicable. These areas specify copays and any additional fees that may apply to maternity care and infertility services.
8. Complete the Prescription Drugs section, noting any necessary information regarding formularies and authorization requirements.
9. Review the Emergency Care section for any urgent care or emergency room services you might need. Record the corresponding copays for these services.
10. Finish by reviewing all entries for accuracy. Once everything is confirmed, save your changes to the form. You may then download, print, or share your completed document as needed.

Complete your document online to ensure you understand your member responsibilities effectively.