Get the free MEMBER ENROLLMENT / CHANGE APPLICATION
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ENR-176 (6-12) www.highmarkbcbsde.com Please detach this sheet before returning this application to your employer. If you are choosing the Blue Care or Blue Select product, please be sure to include
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How to fill out member enrollment change application
How to fill out member enrollment change application:
01
Obtain the necessary form: Start by obtaining a copy of the member enrollment change application form. This form is usually available through your healthcare provider or insurance company. You can also find it online on their official website.
02
Read the instructions carefully: Before filling out the application, it is important to read the accompanying instructions thoroughly. This will help you understand the requirements and any specific documentation needed to complete the form accurately.
03
Provide personal information: Begin by providing your personal information on the application form. This typically includes your full name, date of birth, address, contact information, and any identification numbers associated with your healthcare coverage.
04
Indicate the reason for change: Specify the reason for the enrollment change on the form. Common reasons may include marriage, divorce, birth or adoption of a child, change of employment, or a qualifying life event.
05
Update dependent information: If you are adding or removing dependents from your coverage, make sure to include their details on the form. This may include their names, birth dates, social security numbers, and relationship to you.
06
Verify coverage details: Review and confirm the desired changes to your healthcare coverage. This may involve selecting a different health plan option, adjusting coverage levels, or modifying other benefits.
07
Provide supporting documentation: If required, attach any supporting documentation to verify the requested changes. This may include marriage certificates, birth certificates, divorce papers, or proof of income if you are applying for financial assistance.
08
Sign and submit the application: Once you have completed the form and attached any necessary documents, sign and date the application. Make sure to follow any submission instructions provided, such as mailing it to a specific address or submitting it online through a secure portal.
Who needs member enrollment change application:
01
Individuals experiencing changes in personal circumstances: A member enrollment change application is typically required when individuals experience changes in their personal circumstances, such as marriage, divorce, birth or adoption of a child, change of employment, or qualifying life events.
02
Individuals wishing to update their healthcare coverage details: If you currently have healthcare coverage and need to update details such as adding or removing dependents, changing health plan options, or adjusting benefit levels, you will need to fill out a member enrollment change application.
03
Those seeking financial assistance or subsidy: If you are applying for financial assistance or subsidy programs to help cover the cost of healthcare, a member enrollment change application may be required to provide updated information and assess eligibility.
Remember to contact your healthcare provider or insurance company directly for specific instructions and requirements in filling out the member enrollment change application form.
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What is member enrollment change application?
The member enrollment change application is a form used to update and make changes to a member's enrollment information.
Who is required to file member enrollment change application?
Members or their designated representatives are required to file the member enrollment change application when changes need to be made to enrollment information.
How to fill out member enrollment change application?
To fill out the member enrollment change application, the member or their representative must provide updated information and sign the form.
What is the purpose of member enrollment change application?
The purpose of the member enrollment change application is to ensure that accurate enrollment information is maintained for each member.
What information must be reported on member enrollment change application?
The member enrollment change application must include any updated information such as address, contact information, or changes in household composition.
How do I complete member enrollment change application online?
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