Get 2012 Enrollment Application - Iu Health - Iuhealth

This guide will help you successfully complete the 2012 Enrollment Application for IU Health. It provides clear, step-by-step instructions to ensure you fill out the form accurately and efficiently.

Follow the steps to complete your enrollment application online.

1. Click ‘Get Form’ button to access and open the enrollment application for IU Health.
2. Begin by selecting your desired plan by checking the box next to one of the options: IU Health Medicare Select (HMO), IU Health Medicare Select Plus (HMO), or IU Health Medicare Choice (HMOPOS).
3. Fill in your personal information, including your first name, last name, middle initial (if applicable), birth date, sex, and home phone number.
4. Enter your permanent residence street address. Note that P.O. Boxes are not permitted. Additionally, provide your county, city, zip code, and state.
5. Choose a primary care physician (PCP) by writing their name. Indicate if you are a current patient by circling 'Yes' or 'No', and provide the office location.
6. If your mailing address differs from your permanent residence address, please complete that section. Provide the street address, city, state, and zip code.
7. Optionally, you may include an emergency contact who does not live with you, along with their phone number and relationship to you.
8. Provide your Medicare insurance information by taking out your Medicare card. Complete the Medicare claim number and the effective dates for Parts A and B.
9. Select a premium payment option from the available choices: getting a bill, electronic funds transfer (EFT), or automatic deduction from your monthly Social Security or Railroad Retirement Board (RRB) benefit check. Fill in the necessary banking information if you choose EFT.
10. Answer the required questions about your health status, including End Stage Renal Disease (ESRD) and any other drug coverage. Provide any necessary additional information.
11. Review the important information section regarding the effects of joining the plan on any employer or union health benefits. Ensure you understand these implications.
12. Sign and date the application. If you are completing the form as an authorized representative, include your information and relationship to the enrollee.
13. Once you have completed the form, save your changes and download, print, or share the form as needed.

Complete your enrollment application online today to secure your health plan.