Get Enrollment Form Cn9xan0002

This guide provides step-by-step instructions for completing the Enrollment Form CN9XAN0002 online. Designed to be user-friendly, this guide aims to assist individuals, regardless of their legal knowledge, in efficiently filling out this important enrollment form.

Follow the steps to successfully complete your Enrollment Form.

1. Press the ‘Get Form’ button to access the form and open it in your preferred online editor.
2. In the Group Employer Information section, the Group Benefits Administrator must fill out this part. Include the Subscriber Status by selecting from options such as Active, Retired, or COBRA. Provide the Group Number and Subgroup Number. Additionally, indicate the reason for COBRA if applicable.
3. Record the Employer Name and relevant dates like the Effective Date, Hire/Rehire Date, and COBRA Effective Date. Make sure to include the signature of the Group Administrator and the date signed.
4. Proceed to the Subscriber Plan Section. Check the applicable plans by marking the corresponding checkboxes. Indicate any copayment amounts for services as required.
5. In the Reason for Enrollment/Change section, select the reason that applies, such as New Hire, Open Enrollment, or Adding a Dependent.
6. Fill out the Subscriber Information section carefully. This includes personal details such as Last Name, First Name, Social Security Number, Date of Birth, and contact information.
7. Complete the Primary Care Physician's information by entering their name and number. Confirm if you are a current patient or have verified acceptance.
8. Provide dependent information for each individual you wish to cover. Enter the necessary details such as names, Social Security Numbers, and the relationship. Ensure this section is fully completed for each dependent.
9. Review all information thoroughly. Ensure all required signatures are collected, especially the Subscriber's signature needed for processing.
10. At this final stage, choose to save your changes, download, print, or share the completed form as needed.

Complete your Enrollment Form CN9XAN0002 online today to ensure timely processing!