Get Hap Hmo Enrollment Application

The HAP HMO Enrollment Application is an essential document for individuals looking to enroll in HAP's health maintenance organization plans. This guide will walk you through the process of filling out the application online, ensuring that all necessary information is accurately captured.

Follow the steps to complete the enrollment application successfully.

1. Click ‘Get Form’ button to obtain the form and open it for completion.
2. In the section labeled 'To be filled out by employer', enter the group ID, sub-group ID, class ID, and the effective date of coverage. These details are required for proper enrollment under your employer's plan.
3. Move on to the section 'To be filled out by applicant'. Indicate the type of enrollment by checking the appropriate box for HMO or POS.
4. Provide your last name, legal first name, middle initial, and address. Include your apartment number, city, state, zip code, county, and your primary phone number.
5. Enter your date of birth, date of hire (required) and the name of your personal care physician.
6. For each dependent you are enrolling, list their legal first name, middle initial, last name if different, social security number, and birth date. Specify the sex and tobacco use status for each dependent as applicable.
7. If anyone listed has other health care coverage, indicate whose coverage it is and fill out the related details, including type of coverage, Medicare or Medicaid numbers, and effective dates.
8. Answer if you or any dependents were previously a HAP or Alliance member and provide necessary details if applicable.
9. Review the section regarding qualified medical child support orders (QMSCO), and provide any required documentation if applicable.
10. Finally, ensure that the application is signed and dated by the applicant, certifying that all provided information is accurate and complete.
11. Once you have filled out the form, save your changes. You can then download, print, or share the completed application as needed.

Complete your HAP HMO Enrollment Application online today to ensure proper health coverage.