Get Enrollment Application/ Change Form - Hartwick

Filling out the Enrollment Application/Change Form for Hartwick is a crucial step in managing your healthcare coverage. This guide provides a clear and supportive overview of the form's sections, ensuring users can navigate the process with confidence and ease.

Follow the steps to effectively complete the application form.

1. Press the ‘Get Form’ button to access the Enrollment Application/Change Form and open it in your chosen editor.
2. Begin by filling out the enrollment section, indicating your employment status (full-time or part-time) and related effective dates.
3. Provide necessary personal information including last name, first name, contact details, and address in the subscriber information section.
4. For each dependent, include their name, date of birth, relationship to you, and any relevant healthcare provider selections for HMO plans. Ensure to include their Medicare details if applicable.
5. Indicate any changes in coverage by checking appropriate boxes (e.g., loss of coverage, marriage, etc.) to ensure the correct processing of your application.
6. Fill out any relevant questions regarding other insurance coverage, providing the policyholder name, policy number, and insurance carrier details if applicable.
7. Carefully read and understand the agreement section, confirming that all provided information is accurate, then sign and date the application.
8. Once all sections are complete, review the document thoroughly to ensure no mistakes are present, then save the changes.
9. You may choose to download, print, or share the completed Enrollment Application/Change Form as needed.

Complete your Enrollment Application/Change Form online today to ensure uninterrupted health coverage.