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DE Highmark ENR-176 2014-2025 free printable template

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MEMBER CHANGE FORM COMPLETE THIS APPLICATION IN ITS ENTIRETY IN BLUE OR BLACK INK. DO NOT USE PENCIL OR HIGHLIGHTER. EMPLOYEE/CONTRACT HOLDER INFORMATION Effective Date Employer/Group Name REASON
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How to fill out DE Highmark ENR-176

01
Start by downloading the DE Highmark ENR-176 form from the official Highmark website.
02
Enter your personal information in the designated fields, including your name, address, and contact details.
03
Provide your insurance policy number and any relevant identification numbers.
04
Indicate the type of change you are requesting (e.g., coverage changes, beneficiary updates).
05
Fill out the specific sections relevant to your request according to the instructions provided on the form.
06
Review all entered information for accuracy.
07
Sign and date the form at the bottom.
08
Submit the completed form via mail or fax to the address provided in the instructions.

Who needs DE Highmark ENR-176?

01
Individuals who wish to update their insurance information with Highmark.
02
Policyholders who are changing coverage options or beneficiaries.
03
Patients or caregivers involved in managing health insurance claims.
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DE Highmark ENR-176 is a form used for reporting health insurance enrollment and related data to the Delaware Department of Insurance.
Entities that provide health insurance coverage in Delaware, including insurers and self-insured employers, are required to file DE Highmark ENR-176.
To fill out DE Highmark ENR-176, you need to provide accurate participant information, coverage details, and comply with the state guidelines regarding format and submission deadlines.
The purpose of DE Highmark ENR-176 is to ensure compliance with state regulations and to gather accurate data about health insurance enrollment in Delaware.
The information that must be reported includes the names of covered individuals, types of coverage, effective dates, and any changes in enrollment status.
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