Get Sample Member Qualification Form - Hap - Dweb Hap

Completing the Sample Member Qualification Form - Hap - Dweb Hap is an essential step for maintaining eligibility in the Enhanced plan. This guide provides clear, step-by-step instructions for filling out the form online, ensuring you can navigate the process effortlessly.

Follow the steps to successfully complete your form.

1. Click the ‘Get Form’ button to access the Sample Member Qualification Form - Hap - Dweb Hap and begin your online application.
2. In 'Section 1 – Member Information,' enter your full name, member ID number, date of birth, and the name of your personal care physician (PCP). Ensure all fields are completed accurately. Note the due date for submission.
3. Move to 'Section 2 – Health and Lifestyle Information.' Follow the instructions for your physician to record measurements and lifestyle behaviors. Provide any previous lab results, if applicable, and respond to the wellness targets, ensuring that you select only one option for each condition.
4. In the 'Treatment Plan' section, your physician should document any agreements to treatment plans if relevant, particularly for areas such as blood pressure, blood sugar, and tobacco use. These entries are crucial for the evaluation of your eligibility.
5. Complete the necessary health metrics including height, weight, body mass index (BMI), and any additional specifications required in the lifestyle behavior section, ensuring you adhere to the scoring criteria.
6. In 'Section 3 – Provider Information,' your PCP is required to confirm the accuracy of the submitted data. They will print their name, contact number, sign the form, and provide their NPI number.
7. Once all sections are completed and reviewed for accuracy, you can save your changes, download the document for your records, print a copy, or share it as necessary.

Ready to submit your forms online? Complete the application today to ensure your access to the Enhanced plan.