Get Highmark Enr-164 2015-2025

This guide provides clear and concise instructions to help users complete the Highmark ENR-164 form online. By following these steps, you will ensure that your submission is accurate and complete, facilitating a smooth enrollment process.

Follow the steps to successfully complete the Highmark ENR-164 online.

1. Click the ‘Get Form’ button to obtain the form and open it for filling out.
2. Begin with the employee/contract holder information. Enter the effective date, employer/group name, and group number. Provide your payroll location to ensure proper processing.
3. Indicate the reason for completing the form. If you are adding dependents due to a HIPAA life event (such as birth, marriage, adoption, or other), select the appropriate box and provide the date of the event.
4. If you need to cancel dependents, indicate the reason, such as divorce or death, and provide the corresponding date.
5. For any other changes, such as a new name or address, or if you are becoming Medicare eligible, check the appropriate boxes and include event dates as applicable.
6. Fill in your personal information in the sections provided: first name, middle initial, last name, home/cell phone, address, city, state, zip, date of birth, age, gender, social security number (indicate N/A if none), and employment status.
7. Complete the covered dependent information section. Include relevant details for your spouse or domestic partner, and each dependent child, including their names, dates of birth, social security numbers, and any applicable medical information.
8. Provide information on any other health insurance coverage, including the insurance carrier, policy number, and relationship to the policyholder.
9. Review the important authorized signature section. After reading the information provided, sign and date the form to confirm that the details are true and correct.
10. Finally, make sure to fax or mail the completed form to the appropriate address provided in the instructions. Ensure all attachments are included as necessary.

Complete your Highmark ENR-164 form online today to ensure timely processing of your changes.