Hphc Insurance Company Medicare Enhance

HPHC Insurance Company

CHECK ONE

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ENROLLMENT ________________________________

_________________

Medicare Enhance

(REASON FOR ENROLLING)

EFFECTIVE DATE

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TERMINATION ________________________________

_________________

P.O. BOX 9185 • QUINCY, MA 02169

(REASON FOR TERMINATION)

LAST DAY OF COVERAGE

1-888-888-HPHC(4742)

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ADJUSTMENT ________________________________

_________________

(REASON FOR CHANGE is: ADDRESS, NAME, ETC.)

EFFECTIVE DATE

INSTRUCTIONS

• DO NOT WRITE IN SHADED AREAS

ID NUMBER

GROUP NO.

DIV. NO.

• PLEASE TYPE OR PRINT FIRMLY

• ATTACH A COPY OF MEDICARE CARD

H P E

NAME

FIRST

MIDDLE

LAST

HOME PHONE #

(

)

MAILING

NO. STREET/P.O. BOX

CITY

STATE

ZIP

APT #

COUNTY

SOCIAL SECURITY #

ADDRESS

_

_

HOME

NO. STREET/P.O. BOX

CITY

STATE

ZIP

APT #

COUNTY

DATE OF BIRTH

SEX

ADDRESS

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M

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MO/

DAY/

YR/

F

PLEASE CIRCLE

WHAT LANGUAGE DO YOU SPEAK MOST OFTEN?

THIS INFORMATION WILL HELP US WORK TOWARD BEST MEETING YOUR NEEDS.

ARE YOUR CURRENTLY A HARVARD

LANGUAGE

ASL

CA

CV

EN

FR

HA

HM

IT

KH

LO

MN

PT

RU

SP

VI

OTHER

PILGRIM HEALTH CARE MEMBER?

CODES

American Sign Language

Cantonese Cape Verdean

English

French

Haitian

Hmong

Italian

Khmer Laotian Mandarin Portuguese Russian Spanish Vietnamese

Specify

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YES

NO

ARE YOU CURRENTLY A RESIDENT OF A NURSING HOME?

YES

NO IF YES, GIVE NAME & ADDRESS OF NURSING HOME AND ADMIT DATE BELOW:

/

/

IF YES LIST ID # BELOW:

NAME

ADDRESS

ADMIT DATE

FORMER/CURRENT EMPLOYER

EMPLOYER PHONE #

/

/

DATE OF RETIREMENT (IF APPLICABLE)

ID #

/

/

DATE OF DISABILITY (IF APPLICABLE)

A COPY OF YOUR MEDICARE CARD MUST ACCOMPANY THIS FORM

IN ORDER TO PROCESS YOUR ENROLLMENT.

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IF YOU ARE UNDER AGE 65, IS THE ILLNESS OR CONDITION WHICH QUALIFIES YOU FOR MEDICARE END STAGE RENAL DISEASE?

YES

NO

IF YES, WHAT IS YOUR ENTITLEMENT DATE? __________________________ .

IF NO, STATE THE ILLNESS OR CONDITION WHICH QUALIFIES YOU FOR MEDICARE.

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HAVE YOU HAD A KIDNEY TRANSPLANT?

YES

NO

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ARE YOU COVERED BY MEDICAID?

YES

NO

IF YES, MEDICAID NUMBER______________________________________________________________________________________

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ARE YOU CURRENTLY A MEMBER OF ANOTHER MEDICAL INSURANCE PLAN (EXCLUDING MEDICARE)?

YES

NO

IF YES, PLEASE INDICATE NAME OF PLAN______________________________________________________________ SUBSCRIBER NAME _______________________________________________

EFFECTIVE DATE ______________________________________________________________ POLICY #_________________________________________________________

I UNDERSTAND THAT MEMBERSHIP WILL BECOME EFFECTIVE UPON ACCEPTANCE BY THE PLAN AND THAT BENEFITS UNDER THE PLAN WILL BE EXPLAINED IN A SEPARATE DOCUMENT. DURING MY MEMBERSHIP, I AUTHORIZE ANY HEALTH CARE

PROVIDER OR OTHER HEALTH PLAN TO PROVIDE MEDICAL INFORMATION AND RECORDS TO THE PLAN, THE PLAN ADMINISTRATOR, OR PLAN AFFILIATED HEALTH CARE PROVIDERS. I ALSO AUTHORIZE THE PLAN, THE PLAN ADMINISTRATION, AND

ANY PLAN HEALTH CARE PROVIDERS RENDERING SERVICES TO ME TO RECEIVE COPIES OF MY MEDICAL RECORDS. I AUTHORIZE THE USE BY THE PLAN, AND ITS AGENTS, OF ANY INFORMATION OBTAINED HEREUNDER FOR THE DELIVERY OF

HEALTH SERVICE, TO DETERMINE ELIGIBILITY AND ENTITLEMENT TO BENEFITS (INCLUDING REIMBURSEMENT BY THIRD PARTIES), FOR EDUCATION AND RESEARCH IN ACCORDANCE WITH GOVERNMENT REGULATIONS, AND FOR THE OTHER PLAN

PROFESSIONAL ACTIVITIES SUCH AS UTILIZATION REVIEW, QUALITY ASSURANCE, CASE MANAGEMENT, REFERRAL AND AUTHORIZATION, DISEASE MANAGEMENT, FRAUD DETECTION AND CERTAIN OVERSIGHT ACTIVITIES, SUCH AS ACCREDITATION

AND REGULATORY AUDITS. I UNDERSTAND THAT A COPY OF THIS FORM WILL BE GIVEN TO ME, OR TO MY AUTHORIZED REPRESENTATIVE, UPON REQUEST.

THE EMPLOYEE MUST SIGN THIS FORM FOR ENROLLMENT.

_______________________________________________________________________________

_____________________

_______________________________________________________________________________

______________________

EMPLOYEE SIGNATURE

DATE

EMPLOYER SIGNATURE

DATE

9/02 001-11ME

WHITE - MEDICARE ENHANCE COPY

YELLOW - EMPLOYER COPY

PINK - SUBSCRIBER COPY