Get Highmark Enr-164 2013-2025

Filling out the Highmark ENR-164 form online can be a straightforward process if you follow the necessary steps. This guide provides clear instructions for each section of the form to ensure accurate and complete submissions.

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

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by providing your effective date and employer name in the applicant information section. Ensure the information matches your records.
3. Indicate the reason for completion by selecting the appropriate box. Options include changes, Act 4 dependent, cancel, or COBRA/mini-COBRA.
4. If applicable, fill out the cancel/COBRA reason, including details about your employment situation and group number.
5. Enter your personal details, including first name, last name, street address, city, state, zip, birth date, gender, and marital status.
6. Provide your contact information, including your home/cell phone number and employment status.
7. For covered dependent information, provide necessary details for each dependent, including their social security number, date of birth, relationship to you, and whether they have smoked or used tobacco.
8. If any dependents are over 26 years old, indicate their dependent status and provide documentation if needed.
9. Complete the Medicare information section if applicable, listing any family members eligible for Medicare benefits.
10. Review the important authorized signatures section carefully. Sign and date the form to confirm the information is true and correct.
11. Once completed, save changes, download, print, or share the form as necessary.

Complete your Highmark ENR-164 form online today for efficient processing.