Follow the steps to complete your JD-7 enrollment application.

1. Press the ‘Get Form’ button to access the enrollment application and open it in your preferred editor.
2. Begin by filling out the employee information, which includes providing the employer's name, the reason for application, and your personal details such as your first name, middle initial, last name, street address, city, state, and zip code.
3. Enter your Social Security number and the effective date of coverage. Specify your employment status by checking the appropriate box for Active, Retired, Hourly, or Salary employee and if applicable, include your retirement date.
4. Provide your home and work phone numbers. This information is vital for communication regarding your application.
5. Fill in your hire date formatted as month/day/year, ensuring compliance with HIPAA requirements.
6. Indicate the type of coverage you are enrolling in by selecting the appropriate category: employee only, employee and spouse/domestic partner, or family.
7. Proceed to list all eligible family members in items 15 through 18. Include similar details such as their first name, middle initial, last name, Social Security number, any existing insurance coverage, birth dates, and sex.
8. For each dependent, check the relevant boxes if they exceed the maximum dependent age, if they are disabled, or if they fall under specific categories like Act 4 dependents.
9. Choose your Physician of Record (POR) for yourself and your dependents by providing the full name of the POR Group Practice and its corresponding number from the provider directory.
10. Indicate whether you or the dependent is an established patient of the chosen POR by selecting ‘Yes’ or ‘No.’
11. If applicable, complete the section regarding additional health insurance coverage or Medicare for you, your spouse/domestic partner, or eligible dependents.
12. Make sure to complete any items that are to be filled out by your account administrator.
13. Finally, sign and date the form where indicated. It is recommended to keep a copy for your records once you have submitted the application.

Start filling out your Highmark Blue Cross Blue Shield JD-7 enrollment application online today!