Get the free HEALTHKEEPERS HMO WAIVER FORM
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5665 Lowery Road Norfolk Va. 23502 Phone: 7574222966 Fax: 7574224563HEALTHKEEPERS HMO WAIVER FORM Date: Patients Name: The services or supplies listed below are not covered by your HMO plan. If you
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How to fill out healthkeepers hmo waiver form
How to fill out healthkeepers hmo waiver form
01
Start by obtaining a copy of the Healthkeepers HMO waiver form. This form can usually be found on the official website of Healthkeepers or by contacting their customer service.
02
Read the instructions provided with the form carefully to ensure you understand the requirements and the information that needs to be provided.
03
Fill out your personal information accurately. This usually includes your full name, address, contact details, and social security number.
04
Provide the necessary details about your current health insurance coverage, if applicable. This may include the name of your insurer, policy number, and effective dates.
05
Indicate the reason for requesting a waiver from Healthkeepers HMO. This could be due to having alternative health insurance coverage, being eligible for an exemption, or any other qualifying reason.
06
Attach any supporting documents that may be required. These could include copies of your existing health insurance card, exemption certificate, or any other relevant paperwork.
07
Review the completed form to ensure all information is accurate and complete. Make any necessary corrections or additions before submitting.
08
Sign and date the form. This certifies that the information provided is true and accurate to the best of your knowledge.
09
Submit the completed Healthkeepers HMO waiver form as instructed. This may involve mailing it to a specific address or submitting it electronically through an online portal.
10
Keep a copy of the completed form for your records.
Who needs healthkeepers hmo waiver form?
01
Anyone who wishes to request a waiver from Healthkeepers HMO may need to fill out the Healthkeepers HMO waiver form. This could include individuals who already have alternative health insurance coverage, students who are eligible for an exemption, or those who have a valid reason to opt-out of Healthkeepers HMO.
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