Get 2014 Small Group Application - Memorial Hermann Health Solutions

This guide provides detailed instructions for completing the 2014 Small Group Application for Memorial Hermann Health Solutions online. Each section of the form is explained to help ensure a smooth and accurate application process.

Follow the steps to complete your application successfully.

1. Use the 'Get Form' button to access the application form and open it in your preferred editor.
2. Begin with the Coverage section. Review the available Metal Plans offered by Memorial Hermann Health Insurance Company and select the desired coverage by checking the relevant box.
3. Proceed to Employee Information. Fill in the required fields such as last name, first name, marital status, social security number, and provide your home address, occupation, and employer name. Please ensure to print clearly and use black ink.
4. In the Employee/Dependent Information section, list yourself and any eligible dependents applying for coverage. Ensure to provide accurate information regarding their names, birthdates, and any relevant health coverage details.
5. If declining coverage, fill out the Coverage Declination section. Check the appropriate boxes related to coverage being declined and provide the reason for declining, along with signatures and dates as required.
6. Complete the Other Medical Coverage section by answering the questions truthfully regarding any other group coverage or dental insurance, if applicable.
7. In the Authorization/Disclosure Statement, read the statements carefully and ensure your understanding of the application. Sign and date the form where indicated, noting if your spouse’s signature is needed.
8. Review the completed application for accuracy and completeness. Save your changes, download a copy if needed, and ensure you have printed the application for submission.

Begin your application process by completing the 2014 Small Group Application online today.