Harvard Pilgrim Enrollment Form

CITY OF BROCKTON

Department of Human Resources

Thank you for choosing Harvard Pilgrim Health Care.

Please read the following instructions prior to completing this enrollment/change form. This form may be used for all enrollment transactions (Adding coverage, changing coverage, terminating coverage). In order to add, change or terminate coverage you must (1) experience a qualifying event, (2) complete this enrollment, and (3) provide the completed form to your employer within the allowed timeframe or approved retroactive period.

Qualifying Events:

New Enrollment
Open Enrollment
New Hire Date
Probationary Period (if applicable)
Loss of Insurance
Employment Status Change

Contract Change
Open Enrollment
Marriage/Divorce
Birth/Adoption/Court Order
Loss of Insurance
Loss of Employer Premium contributions

Termination
Open Enrollment
Voluntary Cancellation
Left Employment
Moved from Area
No Longer Eligible (e.g. deceased, LOA, laid off, COBRA nonpayment

Employer Section:Your Employer must fill out this section as well as the Reason for Submission in full for any transactions that this form is used for.

Member Section:Please complete all of the employee sections of this membership application in full. Failure to do so could delay enrollment. You will receive your ID card(s) and member benefit documents after your enrollment has been fully processed. If you are adding or removing a dependent(s), just include the details about the dependent(s) that you are adding or removing off the plan.

* Product/Plan Name: Please be sure to fill in the correct product code for the plan you have selected. Your options are HMO, POS, PPO and Access America. If your employer offers multiple Harvard Pilgrim Plans, please indicate the Plan name as listed on the enrollment materials to help clearly differentiate the plan you are choosing. If you know the Plan MD # (MD0000016670) the number to identify the plan/product please include the information.

* Personal Information: In addition to yourself, please include the personal information for every dependent that will be enrolled on the Plan. IMPORTANT: Social security numbers (or personal tax identification number) for each member on the plan are needed to ensure that federal regulatory reporting requirements are met. Social security numbers are not displayed on the member’s ID card.

* Primary Care Provider: If your plan is an HMO or POS, you will need to select a primary care provider (PCP). If your plan requires one, it is important that you choose a PCP right away. Be sure to fill out this section for all members, including dependents. Write the Harvard Pilgrim PCP ID (not the phone number) and the full name of the doctor you have chosen to coordinate your health care without a PCP assignment, your in-network benefits may be limited to emergency services only. To find a PCP or lookup the PCP ID, visit www.harvardpilgrim.org, and use the doctor search feature available in the Member Section.

* Relation Code: Please use one of the following codes to designate the dependent’s relationship to the Employee:

02 Spouse/Civil Union
03 Child up to age 26
06 Disabled (verification required)
07 Ex-spouse
DP Domestic Partner
SE Spousal Equivalent

When this application is complete: Please sign the enrollment form and provide it to your employer. Your employer will need to sign this form and will forward this application to Harvard Pilgrim Health Care for processing. If you need additional assistance completing this form or selecting a PCP, please call a member services coordinator at 1-888-333-4742.

Coverage underwritten or administered by Harvard Pilgrim Health Care. Harvard Pilgrim Health Care includes Harvard Pilgrim Health Care, Harvard Pilgrim Health Care of Connecticut, Harvard Pilgrim Health Care of New England and HPHC Insurance Company

Reasons for Submission(Required)

New Enrollment/Contract

Change to Contract

Terminate Contract

Qualifying Event Date(Required)

MM slash DD slash YYYY

Qualifying Event(Required)

Open Enrollment

New Hire

Cobra

Loss of Insurance

Court Order

Birth/Adoption

P/T to F/T

Marriage/Divorce

Moved In/Out of Service Area

Death

Voluntary Cancellation

Reason for Change (Check all that apply)(Required)

Change Coverage Type

Add Dependent Listed

Terminate Dependent Listed

Transfer/Re-Enroll to Cobra

Other

Other Reason

SUBSCRIBER INFORMATION

HP ID(Required)

Product(Required)

HMO

PPO

POS

Access America

Plan Name(Required)

Subscriber First Name(Required)

Last Name(Required)

DOB(Required)

Gender(Required)

SSN(Required)

Email(Required)

Home Phone(Required)

Work Phone

Cell Phone

Street Address(Required)

Apt. #

City(Required)

State(Required)

Zip(Required)

Primary Language (Optional)

PCP Full Name(Required)

PCP Town(Required)

Current Patient(Required)

Yes

PCP ID #(Required)

SPOUSE INFORMATION

Spouse First Name

Last Name

DOB

Spouse Gender

Spouse SSN

Spouse Mailing Address

Spouse Relationship Code

Spouse PCP Full Name

Spouse PCP Town

Spouse Current Patient

Yes

Spouse PCP ID #

DEPENDENT INFORMATION

Dependent First Name

Last Name

DOB

Gender

Relationship Code

Mailing Address

SSN

PCP Full Name

PCP Town

Current Patient

Yes

PCP ID #

Dependent First Name

Last Name

DOB

Gender

Relationship Code

Mailing Address

SSN

PCP Full Name

PCP Town

Current Patient

Yes

PCP ID #

Dependent First Name

Last Name

DOB

Gender

Relationship Code

Mailing Address

SSN

PCP Full Name

PCP Town

Current Patient

Yes

PCP ID #

Please check if using additional membership applications for dependent children. Be sure to complete employer and subscriber sections on additional forms.

Yes

Please download, print, and fill in the additional dependent applications, then upload them with his application.
Additional Application.

Please upload additional dependent filled out forms.

Max. file size: 50 MB.

OTHER INSURANCE - IF YOU HAVE NOT COMPLETED THIS SECTION, YOU MAY RECEIVE A FOLLOW-UP QUESTIONNAIRE AND CLAIMS MAY BE DELAYED.

Are you or anyone listed above covered by another Health Insurance Policy at the same time your HPHC Policy is in effect?

Yes

Name of Health Plan

Health Plan Number

Effective Date

Name of Subscriber

MEMBERSHIP WILL BECOME EFFECTIVE UPON ACCEPTANCE BY HARVARD PILGRIM. BENEFITS UNDER THE PLAN WILL BE EXPLAINED IN YOUR EVIDENCE OF COVERAGE (EOC). I UNDERSTAND THAT HARVARD PILGRIM MAY OBTAIN PERSONAL AND MEDICAL INFORMATION TO ADMINSTER THE PLAN. FOR AN EXPLANATION OF HOW WE MAY USE OR DISCLOSE PROTECTED HEALTH INFORMATION, PLEASE READ YOUR NOTICE OF PRIVACY PRACTICES. MAINE MEMBERS: YOU UNDERSTAND THAT YOUR EOC INCLUDES A SUBROGATION PROVISION THAT PERMITS SUBROGATION PAYMENTS TO US ON A JUST AND EQUITABLE BASIS. IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, IMCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPLANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES OR DENIAL OF INSURANCE BENEFITS.

Please upload verification if you selected Disabled for the Relationship Code

Max. file size: 50 MB.

Employee Signature

Date Signed

MM slash DD slash YYYY