Subscriber/member Enrollment Form
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1
2Subscriber/Member Enrollment Form
®
Last Name
First Name
M.I.
Sex
Social Security Number
Street Address
Apt.
City
State
Zip Code
Were you ever a member of HIP?
NO
YES
Marital Status
Birth Date
Telephone #: Home: ( ____ ) _________________ Work: ( ____ ) _________________
Single
Mo.
Day
Yr.
If yes, indicate member ID number(s): _____________________________
E-Mail Address: _____________________________________________
Married
Divorced
Primary Care Physician:
OB/GYN Selection:
Qualifying Event:
Qualifying Event Date:
Birth/Adoption
Marriage
Loss of Coverage
New Hire
______________________
Mo._____ Day_______ Yr.
(not required for EPO/PPO members)
(Optional)
Physician Name
Physician Name
Are you covered by any other Health Insurance or Medicare?
Is your spouse covered by any other Health Insurance or Medicare?
_______________________________
_______________________________
NO
YES If yes, indicate:
NO
YES If yes, indicate:
Physician ID Number
Physician ID Number
Insurance Co. Name: __________________________________
Insurance Co. Name: __________________________________
_______________________________
_______________________________
Insurance Co. Telephone #: ______________________________
Insurance Co. Telephone #: ______________________________
Prior Health Insurance Information
Type of Coverage: ____________________________________
Type of Coverage: ____________________________________
________________________________________
Carrier Name
Policy #: ____________________ Effective Date: ___ / ___ / ___
Policy #: ____________________ Effective Date: ___ / ___ / ___
__ /__ /__
__ /__ /__
Coverage Begin Date
Coverage End Date
* If you are enrolling for your spouse and/or children, please list each one below – see Election of Coverage for eligibility
Primary Care Physician
OB/GYN Selection
Birth Date
Check if
Last Name (if different)
First Name
Soc. Sec. No.
Sex Relationship
Name/Number
Name/Number
disabled
Mo.
Day
Yr.
(not required for EPO/PPO members)
(Optional)
SPOUSE
Wife
Husband
_ _ _ - _ _ - _ _ _ _
Other
Prior Health Insurance Information
Carrier Name ______________________________ Coverage Begin Date__ /__ /__ Coverage End Date __ /__ /__
ADDITIONAL DEPENDENTS (List oldest first)
Son
_ _ _ - _ _ - _ _ _ _
Daughter
Prior Health Insurance Information
Carrier Name ______________________________ Coverage Begin Date__ /__ /__ Coverage End Date __ /__ /__
Son
_ _ _ - _ _ - _ _ _ _
Daughter
Prior Health Insurance Information
Carrier Name ______________________________ Coverage Begin Date__ /__ /__ Coverage End Date __ /__ /__
Son
_ _ _ - _ _ - _ _ _ _
Daughter
Prior Health Insurance Information
Carrier Name ______________________________ Coverage Begin Date__ /__ /__ Coverage End Date __ /__ /__
Son
_ _ _ - _ _ - _ _ _ _
Daughter
Prior Health Insurance Information
Carrier Name ______________________________ Coverage Begin Date__ /__ /__ Coverage End Date __ /__ /__
Your signature is required to process this form. Your signature attests that you have read the reverse side of this form
Applicant must sign here: _______________________________
Date________________
THIS SECTION TO BE COMPLETED BY EMPLOYER/CONTRACTOR GROUP
I
Name of Group
Group Number
Select One:
HIP PRIME HMO
HIPaccess
HIP PRIME EPO
II
HIP PRIME POS
HIPaccess
HIP PRIME PPO
HIP SELECT EPO
HIP SELECT PPO
HIP CLASSIC HMO
Requested Effective Date
Hire Date
Employee Title
Date Submitted to HIP
Approved by (Representative of Benefits Administrator)
Type of
Individual
Family
Coverage:
Employee & Spouse
Employee & Child
FOR HIP USE ONLY
Instructions to Benefit Administrators or Group Representatives: For Groups with 50 employees or less, you MUST complete
PROCESSED BY
RECEIVED DATE
PROCESSED DATE
Section A on the reverse side of this form. Required documentation MUST be attached to this Enrollment Form to be processed.
HIP HEALTH PLAN OF NEW YORK, P.O. Box 2806, New York, NY 10116-2806
FORM 16-1613 10/02
9798/m
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