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Get the free LGHP Member Enrollment Form - Illinois.gov - www2 illinois

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LOCAL GOVERNMENT HEALTH PLAN Member Enrollment Form Unit Name:Member Name:MEMBER BIOGRAPHICAL INFORMATION (Please Print or Type) Temporary SSN:Member SSN:YesNoOrg. Pro. Code:Eff. Date of Add:Name
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How to fill out lghp member enrollment form

01
Start by reading the instructions provided on the LGHP member enrollment form.
02
Fill in your personal information, such as your name, address, date of birth, and contact details.
03
Provide information about your current healthcare coverage, including the name of your current health insurance provider and policy number.
04
Indicate your preference for primary care providers and specialists, if applicable.
05
Declare any pre-existing medical conditions or medications you are currently taking.
06
Review and sign the consent and authorization section of the form.
07
Make sure to complete all the required fields and provide any additional supporting documents if requested.
08
Double-check your form for accuracy before submission.
09
Submit the filled-out LGHP member enrollment form through the designated submission method, such as mailing it to the provided address or submitting it online.
10
Keep a copy of the filled-out form for your records.

Who needs lghp member enrollment form?

01
Anyone who wishes to enroll in the LGHP (Local Government Health Plan) needs to fill out the LGHP member enrollment form. This includes current or new members who want to join the LGHP healthcare coverage or make changes to their existing plan. The form is applicable for individuals, families, and dependents who are eligible for LGHP membership.
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The LGHP member enrollment form is a document used to enroll in the Local Government Health Plan.
All employees of the local government who wish to enroll in the health plan are required to file the LGHP member enrollment form.
To fill out the LGHP member enrollment form, employees must provide personal information, dependent information, and select their desired coverage options.
The purpose of the LGHP member enrollment form is to collect information from employees who wish to enroll in the Local Government Health Plan.
The LGHP member enrollment form requires employees to report personal information, dependent information, and select their desired coverage options.
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