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I authorize EMI Health to share PHI concerning me and my family including adult dependents with any health care provider or HSA administrator providing benefits. I Signature of Applicant EMPLOYER SIGN OFF SECTION New Enrollment Change of Coverage Application D ate Special Enrollment Add Family Member Employer Signature Name/Address Change Cancelation Beneficiary Change Delete Family Member Effective Date Return To ALPINE UNISERV / AEA 557 W. Center Street Pl. Grove UT 84062 FAX...
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Read the instructions on the enrollment application form carefully.
02
Gather all the necessary documents and information needed to fill out the application.
03
Start by providing your personal details such as name, date of birth, and contact information.
04
Fill in the sections related to your educational background, including schools attended and degrees earned.
05
Provide information about your work experience, including previous employers and job positions held.
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If applicable, include any certifications or licenses you hold that are relevant to the enrollment.
07
Complete the sections related to your desired program or course of study, including specific requirements or preferences.
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Submit the completed enrollment application form by the specified deadline.
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Keep a copy of the submitted application for your records.

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