Highmark ENR-164 2020-2025 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 DateEmployer/Group NameREASON FOR
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How to fill out Highmark ENR-164
01
Obtain the Highmark ENR-164 form from the Highmark website or your healthcare provider.
02
Fill in the top section with your personal information, including your name, address, and date of birth.
03
Provide insurance information, such as policy number and group number.
04
Complete the section regarding dependent information, if applicable.
05
Indicate the type of change you are reporting (e.g., new address, change of dependent status).
06
Review the form for accuracy to ensure all information is correctly filled out.
07
Sign and date the form at the designated area, certifying that the information is true.
08
Submit the form according to the provided instructions, either by mail or online.
Who needs Highmark ENR-164?
01
Individuals enrolled in Highmark health insurance plans who need to report changes in personal information.
02
Dependents covered under a Highmark insurance plan needing to update their details.
03
Employers who manage health benefits through Highmark and need to ensure accurate employee information.
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What is Highmark ENR-164?
Highmark ENR-164 is a form used for the reporting of employment-related information to Highmark, typically related to insurance and benefits.
Who is required to file Highmark ENR-164?
Employers and entities that provide health insurance coverage or benefits through Highmark are required to file Highmark ENR-164.
How to fill out Highmark ENR-164?
To fill out Highmark ENR-164, gather the necessary employment and insurance information, complete each section of the form accurately, and ensure all mandatory fields are filled before submission.
What is the purpose of Highmark ENR-164?
The purpose of Highmark ENR-164 is to collect information regarding employee eligibility for health benefits and to maintain accurate records for insurance providers.
What information must be reported on Highmark ENR-164?
Information reported on Highmark ENR-164 includes employee details such as name, social security number, employment status, and details regarding their health insurance coverage.
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