Get Highmark Enr-163 2012-2025

The Highmark ENR-163 form is a member change application essential for updating your insurance information. This guide will help you complete the form accurately and efficiently online, ensuring all necessary sections are addressed.

Follow the steps to fill out the Highmark ENR-163 form online.

1. Click ‘Get Form’ button to access the Highmark ENR-163 form and open it in your preferred editor.
2. Complete the employee application information section. Enter your effective date, employer name, and reason for completion from the options provided: changes, Act4, cancel, or COBRA. Ensure all fields are filled out in blue or black ink; avoid using pencil or highlighter.
3. Fill out the dependent changes section. Indicate whether you are adding dependents due to birth, marriage, or adoption, and provide the date of that event. If you are dropping dependents, specify if it is due to divorce, death, or other reasons and provide the corresponding date.
4. For each covered dependent, list their relationship to you (e.g., spouse, partner, child) and include their birth dates. If a dependent is over age 26 and disabled, select the appropriate box.
5. Complete the other changes section. Here, indicate if there is a new name, address, or any change to Medicare eligibility or coverage. Provide details where necessary.
6. In the cancellation/COBRA reason section, select the appropriate box (e.g., deceased, left employment, involuntary lay-off) and enter the corresponding dates where required.
7. Provide your social security number, gender, marital status, employment status, and any other personal information requested in this section.
8. If applicable, fill in the covered dependent information. Ensure you provide the social security number, birth date, and gender of each dependent along with their dependent status if over age 26.
9. Complete the Medicare information section by listing any family member eligible for Medicare benefits and providing the necessary details, including effective dates and claim numbers.
10. Finally, review the important authorized signatures section. Ensure you provide both your signature and the authorized employer’s signature along with the dates. Verify that all information is accurate and complete.
11. Once all sections are completed, you can save changes, download, print, or share the Highmark ENR-163 form according to your needs.

Start completing your Highmark ENR-163 form online today!