HOW TO COMPLETE YOUR HIGHMARK BLUE SHIELD ENROLLMENT APPLICATION

FOLLOWING ARE INSTRUCTIONS FOR COMPLETING THE HIGHMARK BLUE SHIELD ENROLLMENT APPLICATION.
ALL INFORMATION MUST BE COMPLETED AS INDICATED.

EMPLOYEE INFORMATION Items 15 through 18 ask for important information about a) Full Name of Physician of Record (POR) Group
yourself and each eligible member of your family (15 Practice — Indicate the name of the POR Group
The first thirteen (13) items ask for information regarding
yourself, 16 your spouse/ domestic partner, 17-18 your Practice selected from the Online Provider Directory
the employee. The information you must complete includes:
dependents). Please complete all requested information. for yourself and each of your dependents. You and
1) Employer Name and Reason for Application If relationship is “other”, please indicate the dependent’s your dependents can each choose a different POR.
2) Employee First Name, Middle Initial, Last Name. relationship to the employee according to the codes b) Physician of Record (POR) Number from Provider
provided on the application. Directory — Please indicate the corresponding
3) Employee Street Address
• First Name/Middle Initial/Last Name — Complete number for the physician practice you or your
4) City
the First Name, Middle Initial and Last Name for each dependent chose as a POR from the Online Provider
5) State eligible person listed. Directory, Practice Information tab.
6) Zip Code • Social Security Number — Please include the Social c) Are you an existing Patient of this POR? — Please
7) Employee Social Security Number Security Number of each person. check “Yes” or “No” to indicate if you are currently
• Do you have other insurance? — If you or a family a patient of the POR you chose for yourself or your
8) Effective Date of Coverage
member have other medical insurance including dependents.
9) Employee Status: Please check () the appropriate
Medicare, respond “yes”. If not, you must respond For online provider lookup, go to www.highmarkblueshield.com
box indicating whether you are an Active, Retired,
“No”. and search under the “Find a Doctor or Rx” tab. If you need
Hourly or Salary employee. If retired, please indicate
• Birth Date (month/day/year) assistance with choosing a POR, please call Member Service
retirement date.
at 1-800-345-3806.
10) Employee Home Phone Number (including area code) • Sex (female or male)
Disclaimer: Please note that a provider number may not
– Please provide so that we may contact you if we • Check if: Student over Maximum Regular be available for providers that are located outside of the
have questions about your application and to better Dependent Age, Disabled and/or Act 4 dependent local servicing area. In this case, a POR cannot be chosen.
serve you. If your dependent is over the Maximum Regular
Dependent Age and is a full time student or 19) Needs to be completed if you, your spouse/domestic
11) Employee Work Phone Number (including area code)
a disabled dependent of any age or an Act 4 partner or one of your eligible dependents has other
12) Employee Hire Date (i.e., date employee first eligible health insurance coverage or is eligible for Medicare.
dependent to the age of 30 (see your benefit
to enroll for benefits) – Specify month/day/year. Please complete all information requested. Refer
administrator for eligibility), please check () the
Required under the Health Insurance Portability and to your Medicare card to complete the Medicare
appropriate column by that dependent’s name.
Accountability Act of 1996 (HIPAA). Information section.
Physician of Record (POR) Information — A Physician
13) Check Type of Coverage for which you are enrolling, 20) Should be completed by your Account Administrator.
of Record is the physician selected by the member, who
using the appropriate category (employee, two person
provides routine care and coordinates other specialized
or family). 21) You must sign and date the form where indicated.
care. Please note that choosing a POR does not impact
14) To be completed by Account/Administrator only your benefits or claims payment in any way. Choosing a
POR simply helps us to better serve you by connecting you Once the form is completed, retain the last copy for your
to the practice where most of your health care is received. records.

6206 (R4-15) Highmark Blue Shield is an independent licensee of the Blue Cross and Blue Shield Association ENR-6206 (R11-16)
HIGHMARK BLUE SHIELD ENROLLMENT APPLICATION P.O. Box 890172
Camp Hill, PA 17089
EMPLOYEE INFORMATION — Employee must complete items 1 through 17 and sign.
1) Employer Name Reason for Application qEnrollment
qNew Hire qRehire qCOBRA 13) Check Type of Coverage MEDICAL DENTAL VISION DRUG PRODUCT NAME
qAct 4 qOther:
2) Employee First Name / Middle Initial / Last Name
Employee Only q q q q q
Insured & Spouse/Domestic Partner q q q q q
3) Street Address 4) City 5) State 6) Zip Family q q q q q
Parent & Child q q q q q
7) Social Security Number 8) Effective Date of Coverage 9) Employee Status Parent & Children q q q q q
Month Day Year qActive qHourly
14) To be completed by Account Administrator only
qRetired (Date) qSalary
10) Employee Phone #—Home 11) Employee Phone #—Work 12) Employee Hire Date Group Number Report Code Qualifier Report Code Value
Month Day Year
( ) ( )

Do you Check If
have other Birth Date Sex
Complete items 15 through 18 where applicable. List eligible participants. (If you have additional dependents, attach separate sheet.) F/M
Student
Dis- Act
insurance? Benefits
Mo Dy Yr Apply abled 4
First Name / Middle Initial / Last Name Social Security Number
15) Self qYes qNo
If YES, then
complete #19

a) Full Name of Physician of Record (POR) Group Practice b) POR Number from Provider Directory c) Are you an Established Patient? qYes qNo
16) qSpouse First Name / Middle Initial / Last Name Social Security Number
qYes qNo
qDom. Part.* If YES, then
complete #19

a) Full Name of Physician of Record (POR) Group Practice b) POR Number from Provider Directory c) Is Spouse/DP an Established Patient? qYes qNo
17) qChild First Name / Middle Initial / Last Name Social Security Number qYes qNo
qOther* If YES, then
complete #19

a) Full Name of Physician of Record (POR) Group Practice b) POR Number from Provider Directory c) Is Dependent an Established Patient? qYes qNo

18) qChild First Name / Middle Initial / Last Name Social Security Number
qYes qNo
qOther* If YES, then
complete #19

a) Full Name of Physician of Record (POR) Group Practice b) POR Number from Provider Directory c) Is Dependent an Established Patient? qYes qNo

*If “domestic partner” or “other” applies, complete using one of the following codes: (05) Grandchild, (07) Nephew or Niece, (17) Stepson or Stepdaughter, (29) Domestic Partner

19) If you checked YES to other insurance, fill in appropriate line: MEDICARE INFORMATION: List any family member that is eligible for Medicare Benefits:
Name of Member Health Insurance Part A Effective Part B Effective Part D Effective
Name of Insurance Carrier:
Last First Claim Number Date (Mo-Day-Yr) Date (Mo-Day-Yr) Date (Mo-Day-Yr)
Group No: Effective Date:
/ / / / / /
Name of Policy Holder:
/ / / / / /
Policy Number:
/ / / / / /
Relationship to Highmark Policy Holder:
Policy Holder Date of Birth:
Why are you eligible for Medicare? q Age q Disability q End Stage Renal Disease
Policy Holder Employment Status: q Active q Retired (Date) Do you have a Medicare Supplement or other coverage that complements Medicare? qYes qNo

To the best of my knowledge and belief, the information provided on this application is true and correct. Any person who knowingly be covered. I acknowledge and agree that any personally identifiable health information about me or my enrolled dependents (“Protected
and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing Health Information”) is protected by The Health Insurance Portability and Accountability Act of 1996 (HIPAA) and other privacy laws, and
any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits that, in accordance with those laws, Highmark Health Services may use and disclose Protected Health Information for payment, treatment
a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. I understand that this form enrolls and health care operations as described in its Notice of Privacy Practices. I understand that a copy of Highmark Health Services’ Notice of
those eligible persons listed above in the Medical Plan as described in the agreement between the plan and my employer. I authorize Privacy Practices is available on Highmark Health Services’ Web site, or from the Highmark Health Services Privacy Office.
any payroll deductions required for the coverage and recognize that I must formally enroll my dependents on this form or they will not

20) 21)
Authorized Employer Signature Date Employee Signature Date
Highmark Blue Shield is an independent licensee of the Blue Cross and Blue Shield Association ENR-6206 (R11-16)