Get Selecting Health Coverage Through The State Health Plan

Filling out the Selecting Health Coverage Through The State Health Plan form online can be a straightforward process if you follow the right steps. This guide provides clear instructions on completing each section of the form to ensure your health coverage needs are met efficiently.

Follow the steps to successfully complete your health coverage selection.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. In Section A, provide your first name, middle initial, last name, social security number, date of birth, and mailing address. Include your city, state, county, ZIP code, marital status, and gender.
3. In Section B, select your marital status among single, married, separated, widowed, or divorced. Enter your telephone number.
4. Section C requires you to indicate the reason for updating your coverage. Check the appropriate box that applies to your situation.
5. In Section D, please check the type of coverage you desire. Options may include various plans such as the Indemnity Plan or the PPO plans.
6. Section E allows you to choose which family members you want coverage for. Options include retiree only, retiree and child(ren), retiree and spouse, or retiree and family.
7. In Section F, if applicable, detail any events that prompted the need to modify your coverage and provide relevant dates.
8. Section G requires you to list family members to be added or removed from coverage. Provide their first name, last name, gender, date of birth, and Medicare eligibility status.
9. Section H asks for information about Medicare eligibility for you and any listed family members.
10. In Section I, include details of any other group health policy if applicable, that covers you or your dependents.
11. Section J is where you provide your signature to authorize the coverage selection and confirm the accuracy of the information provided.
12. Finally, submit the completed form by mailing or faxing it to the address provided. You may also save changes, download, print, or share the document.

Complete your health coverage selection online today to ensure you have the necessary protection.