Get Application For Individual Coverage - Amerihealth New Jersey

This guide provides clear and detailed instructions on how to complete the Application For Individual Coverage - AmeriHealth New Jersey online. It is designed to help you navigate the form smoothly and efficiently, ensuring a straightforward application process.

Follow the steps to fill out the application accurately.

1. Press the ‘Get Form’ button to obtain the application and open it in the editor.
2. In section A, select the type of activity you are applying for. Indicate whether you are enrolling a new subscriber, adding or removing a spouse, partner, or dependent child, or making other changes. Specify the date of the event related to these actions.
3. Proceed to section B to fill out your personal information. Provide your full name, social security number, birthdate, email address, and check the appropriate box regarding your gender. Confirm residency by indicating if you reside in New Jersey.
4. Complete the address information section, including both your primary and any additional residential addresses, along with contact numbers.
5. In section C, select your medical plan option, and choose the required pediatric dental options, ensuring compliance with the Patient Protection and Affordable Care Act (PPACA).
6. In section D, identify any additional individuals you are adding, changing, or removing from coverage. Provide necessary information for each person, including name, birthdate, and any applicable healthcare provider information.
7. If applicable, complete sections E and F to provide additional addresses for your spouse, domestic partner, or children. Include necessary explanations for different addresses.
8. In section G, you have the option to share your race or ethnicity, though this response is appreciated but not mandatory.
9. Select your payment information in section H, indicating your preferred billing method.
10. Finally, ensure you provide your signature and the date in section I, confirming that all provided information is accurate.
11. After completing the form, review all information for accuracy, save any changes made, and choose to download, print, or share the form as needed.

Feel empowered to complete your Application For Individual Coverage - AmeriHealth New Jersey online and ensure you have the coverage you need.