Get All Dates Mmddyy

Filling out the All Dates Mmddyy form can be straightforward when you understand each section and requirement. This guide will provide you with a detailed walkthrough to ensure that your submission is accurate and complete.

Follow the steps to successfully complete the All Dates Mmddyy form.

1. Press the 'Get Form' button to access the All Dates Mmddyy form and open it in your preferred editor.
2. Begin with the Group Employer Information section. This must be completed by the Group Benefits Administrator. Use blue or black ink, ensuring that you print one character per box. Enter the HIOS ID, Employer Name, and group numbers as required.
3. Indicate the Subscriber Status and select the reason for COBRA if applicable. Make sure to include the Effective Date and the signature/date of the Group Administrator.
4. Proceed to the Subscriber Plan section. Here, fill out the Department Number, Employee Number, and select the coverage type(s) that apply to the subscriber.
5. In the Reason for Enrollment/Change section, indicate why the enrollment or change is happening, whether due to a new hire, loss of coverage, or other reasons. Provide any requested subscriber and dependent information.
6. Complete the Subscriber Information section by entering the subscriber's last name, first name, date of birth, and contact information accurately. Ensure that you complete both sides of the application.
7. For Additional Coverage Information, indicate if you or any family member have any other health or dental insurance. Include details like the name of the other insurance carrier and policy information if applicable.
8. Lastly, ensure that you sign and date the Release/Signature section. This signature is required to process the application. Review all entered information for accuracy before finalizing.
9. Once you have completed the form, save your changes, and options will be available for downloading, printing, or sharing the completed document.

Take the next step in your health coverage by completing your documents online today.