Get Member Application And Change Form Instruction - Upmc Health Plan

Filling out the Member Application And Change Form for UPMC Health Plan is a straightforward process that allows individuals to enroll or make changes to their health insurance coverage. This guide provides clear instructions to help users effectively complete the form online.

Follow the steps to complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Select a plan: Review the health plans available to you, including HMO, EPO, EAPOS, PPO, and others. Choose one option based on what your employer offers.
3. Indicate your applicant status: Check all applicable boxes for membership application, annual enrollment, new hire, change, or qualifying event. Also specify your type of coverage (e.g., employee only, employee and children, etc.).
4. Provide employee information: Fill in your full name, date of birth, contact telephone numbers, home address, employer name, Social Security number, and date of employment.
5. List covered family members: Include the information of yourself and each dependent you wish to cover, including full name, Social Security number, sex, date of birth, and email address. Ensure accuracy as this information will be part of your health record.
6. Provide information about other group health insurance: If you or any dependents have other health coverage, provide the necessary details, including the name of the other insurer and policy number.
7. Signature: Ensure that you sign and date the form at the designated fields, keeping a copy for your records, and follow your employer's instructions for submitting the completed form.

Complete your Members Application And Change Form online today for a seamless health coverage experience.