Get 2012 Enrollment Request Form - Providence Health Plans - Healthplans Providence

Filling out the 2012 Enrollment Request Form for Providence Health Plans can seem daunting, but it is a straightforward process. This guide will help you understand each section of the form, ensuring you provide the necessary information accurately and efficiently.

Follow the steps to complete your enrollment request accurately.

1. Press the ‘Get Form’ button to access the Enrollment Request Form. This will open the document in the editor for you to fill out your information.
2. Provide your personal details, including your last name, first name, middle initial, birthdate, sex, and home phone number in the designated fields.
3. Complete the address sections by entering your permanent residence street address and mailing address if it differs from your permanent address. Note that a P.O. Box is not allowed for the permanent address.
4. Fill in your emergency contact information, including their name, phone number, and relationship to you.
5. Next, provide your Medicare insurance information by entering your Medicare card details. If necessary, attach a copy of your Medicare card or supporting documents.
6. Select the payment option for your plan premiums. You can choose between receiving a monthly bill, setting up an electronic funds transfer (EFT), or automatic deduction from your Social Security or Railroad Retirement Board benefit check.
7. Respond to the questions regarding your health status, existing coverages, and eligibility for special enrollment periods. Be thorough and accurate in your answers.
8. Choose a Primary Care Physician (PCP) from the list provided or enter one if you have a preference.
9. Carefully read the important information provided. Confirm your understanding by checking the appropriate boxes indicating your attestation of eligibility for enrollment.
10. Finally, sign and date the form. If applicable, have your authorized representative sign and provide their information as well.
11. Once you have filled out the form completely, save your changes, download a copy of the completed form, print it for your records, or share it as necessary.

Complete your enrollment request form online today and ensure you have the health coverage you need.