Get Existing Group - Member Enrollment Form - Vantage Health Plan, Inc.

This guide provides step-by-step instructions to assist you in accurately completing the Existing Group - Member Enrollment Form for Vantage Health Plan, Inc. Filling out this form online ensures a smooth enrollment process and ensures that your information is correctly captured.

Follow the steps to complete your enrollment form.

1. Click the ‘Get Form’ button to acquire the enrollment form and open it for editing.
2. In Section 1, provide your personal information. Fill in your last name, first name, middle initial, sex, birth date (in MM/DD/YYYY format), mailing address, marital status, social security number, and optional email address. Include your home phone, cell phone, and parish.
3. Move to Section 2 and enter the employer information for yourself and, if applicable, your spouse. Indicate the type of coverage desired (employee only, employee & child(ren), employee & spouse, or family) and provide the employer's address, phone number, and your job title. Clearly state whether health insurance is available through your spouse’s employer.
4. In Section 3, list the dependents and spouse that will be covered by Vantage Health Plan. Complete their full names, social security numbers, relationships, birth dates, sex, weight, height, and select a primary care physician for each listed individual.
5. Proceed to Section 4 where you will indicate any other health insurance coverage you have. Answer the questions regarding existing coverage and select the applicable types, like Medicare or group health insurance. List all health insurance coverage and indicate which coverage you will keep after enrolling with Vantage.
6. In Section 5, sign the acknowledgments and authorizations. Confirm your understanding of the release of medical records and your rights regarding genetic information. Sign and date as the applicant/employee and ensure your employer signs as well.
7. Review all the information for accuracy. At this final step, you can save any changes, download the completed form, print it for your records, or share it as needed.

Complete your existing group member enrollment form online to ensure your enrollment with Vantage Health Plan, Inc. is processed smoothly.