Health Tradition Member Enrollment Form
Download a blank fillable Health Tradition Member Enrollment Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Health Tradition Member Enrollment Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3Send to: Health Tradition Health Plan
Member Enrollment Form
Mayo Clinic Health Solutions
PO Box 211698
Eagan, MN 55121
❏ New employee
❏ Return to work
❏ Increase in hours
Please complete, print and submit.
❏ Lost other qualifying coverage (complete Termination of Coverage Attestation section)
Coverage effective date: _______________________ (after completing waiting period, if applicable)
Reset Form
Print
Name: ___________________________________________________________________________________________
Employee
Last
First
M.I.
Information
Previous Name(s) if any: _____________________________________________________________________________
Complete each
field. After we
Social Security No.: ________________________________________
have received this
Member Enrollment
Date of Birth (MM/DD/YY): ___________________________________
Gender: ❏ Female ❏ Male
Form, we will mail
your membership
Address: _____________________________________
City/State/ZIP Code: _________________________________
information to your
home address.
Telephone No.: ________________________________
Marital Status: ❏ Single ❏ Married
Primary Care Provider Name/Location: __________________________________________________________________
Employer Name: ___________________________________________________________________________________
Employment
Information
Group No.: __________________________________
Job Location: _______________________________________
Job Title: ____________________________________
Hire/Rehire or Full-Time Date: __________________________
Hours Worked Weekly: _________________________
Employment Status: ❏ Active
❏ Full Time
❏ Retired
Plan Option Selected: __________________________
❏ Part Time ❏ Cobra: Start/End date:
____________________
Name: ___________________________________________________________________________________________
Spouse
Last
First
M.I.
Information
Previous Name(s) if any: _____________________________________________________________________________
Complete each field
if applicable.
Social Security No.: ________________________________________
If your spouse is not
enrolling in the plan,
Date of Birth (MM/DD/YY): ___________________________________
Gender:
❏ Female ❏ Male
do not complete
this section.
Primary Care Provider Name/Location: __________________________________________________________________
Complete address
only if different
Home Address: ________________________________
City/State/ZIP Code: _________________________________
than employee.
Telephone No.: ________________________________
Dependent children living with spouse?
❏ Yes
❏ No
RELATIONSHIP TO
DATE OF
Eligible
NAME
APPLICANT
BIRTH
GENDER
Dependent
Information
LAST
FIRST
M.I.
(MM/DD/YY)
F
M
Complete each field on
the grid if applicable.
Social Security No.
Primary Care Provider Name/Location
If your dependents
are not enrolling in the
plan, do not complete
this section.
Social Security No.
Primary Care Provider Name/Location
If adding dependents,
Social Security Number
and Primary Care
Social Security No.
Primary Care Provider Name/Location
Provider Name/Location
must be entered.
Adult children are eligible for coverage up to the end of the month in which they turn 26.
Does anyone listed on this application currently have Medicare coverage? ❏ Yes
❏ No
Medicare
Information
If yes, please complete this information below and attach a copy of the Medicare ID card:
Name of person covered by Medicare ___________________________________________________________________
Medicare claim number _____________________________________________________________________________
Medicare eligibilty due to:
❏ Over age 65
❏ End-Stage Renal Disease (ESRD)
❏ Total disability
Part A Effective date _______________ Part B Effective date _______________Part C Effective Date ______________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical