Sample Enrollment Confirmation Letter Template

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Sample Enrollment Confirmation Letter
SALLY SAMPLE
35 W MAIN ST
ANY TOWN, PA 17815
12/9/2015
POLICY EFFECTIVE DATE: 01/01/2016
TOTAL MONTHLY PREMIUM: $259.58
SUBSIDY AMOUNT: $100.00
MEMBER RESPONSIBILITY AMOUNT: $159.58
MEMBER ID: 1231231231200
Dear Member:
This is a reminder that you are enrolled in the Individual Comprehensive Major Medical Non-Gatekeeper
Preferred Provider Agreement. This Agreement is identified as <Insert Plan Name> (Agreement). You should have
received your <Insert Plan Name> Plan Agreement and identification (ID) card in the mail.
This letter includes details about your effective date and monthly premium. Please keep it with your Agreement.
If the information is correct, you do not need to take action.
For questions about your coverage, please call Member Service. The toll-free number is <Customer Service
Phone>. You can call between 8 a.m. and 8 p.m. EST, Monday through Friday.
If you need help because you have a disability or if English is not your first language, please call <Customer
Service Phone>. Or call TTY at 711 to get free help.
Highmark Individual Markets

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