Follow the steps to complete your enrollment form correctly.

1. Click ‘Get Form’ button to obtain the form and open it in the designated editor.
2. Begin with the subscriber information section. Fill in the first name, middle initial, last name, and person code. Ensure that you provide the date of birth in the format MM/DD/YYYY.
3. Next, provide your mailing address, including the city, state, zip code, and phone number. Also, be sure to include your email address.
4. Indicate your customer status by selecting either 'I am an existing Hannaford Pharmacy customer' or 'I am a NEW Hannaford Pharmacy customer'.
5. If you are enrolling dependents, enter their information in the enrollment information for dependents section. For each dependent, fill in the first name, middle initial, last name, person code, relationship, and date of birth.
6. In the allergies section, list any known allergies for the subscriber and dependents as applicable.
7. Read the HIPAA authorization terms carefully. Understand that your signature authorizes the use of the information you provide for administering the program.
8. Sign and date the authorization sections as indicated, ensuring that you verify your relationship if signing for dependents.
9. Upon completion of the form, you may save changes, download, print, or share the form as needed before submission.

Take the next step towards your health savings by filling out the enrollment form online today.