Alabama Health Insurance Premium Payment Application Form printable pdf download

ALABAMA HEALTH INSURANCE PREMIUM PAYMENT APPLICATION FORM

Please fill out questions 1-5 with applicant’s personal information.

1. Name:

2. Social Security Number:

3. Address:

4. Area Code/ Phone Number:

5. □ EMAIL

Yes, once available, I choose to receive emails from HIPP that will include

(Check box to sign up for email notifications.):

important information about the program and my payments. I understand that my email will not be used for anything

other than HIPP correspondence.

Email Address: _________________________________________________________________

6. How did you hear about HIPP

(choose an option below)

□ Mail

□ Medicaid

□ Online search

□ Health related

□ Other:________________________________

Caseworker

engine

support group

7. Policyholder’s Name:

8. Policyholder’s Date of Birth:

9. Policyholder’s Social Security Number:

10. Policy Number:

11. Insurance Carrier Name:

12. Policy Start Date:

: □ Individual □ Individual + Child(ren) □ Individual + Spouse □ Family

13. Type of policy coverage

(Check One)

? □ Insured pays Insurance Carrier □ Insured pays Employer □ Payroll deduction

14. How are premiums paid

(Check One)

? □ Employer □ Cobra □ Private □ Other □ None

15. What type of health insurance do you have access to

(Check One)

Employer or COBRA insurance policyholders, please continue to question 16. Private or Other policyholders, please skip down to 21.

16. Open enrollment dates for health insurance obtained from employer? Start: ____/____/____ End: ____/____/____

17. Name of Employer:

18. Employer Telephone:

19. Employer Mailing Address:

20. Federal Employer Identification Number (FEIN):

21. What is the premium for this policy

? $ _______ These premiums are deducted/ paid:

(if known)

□ Weekly

□ Every other

□ Twice a

□ Monthly

□ Every three

□ Other

week

month

months

22 List everyone in your household covered by your policy, including Medicaid recipients.

(Use extra paper if necessary.)

Name

Medicaid ID

Social Security

DOB

Medical Condition

Is this

Relationship to

Number

(Diabetes, asthma, etc)

person

policyholder

pregnant?

Submitting “Medical Condition” is optional, although, listing this specific information may benefit the applicant.

23 □ DIRECT DEPOSIT

: If accepted onto the HIPP program, once this option is available, I

(Check box to sign up for Direct Deposit)

would like to participate in the Direct Deposit program. By doing so, HIPP will deposit my payments into my checking

account and I will not receive a paper check. If I am not accepted onto the program, HIPP will properly discard my banking

information. Bank Name:

______________________________________________ Routing #: ________________________

Checking Account #: ______________________________________

(Please provide a copy of your voided check with this application.)

24. □ EMPLOYER CONTACT

: The HIPP program has permission to contact my employer to verify

(Check box if you agree.)

employer information that is necessary to process my HIPP application.

25. APPLICANT’S AGREEMENT: The information you provided will be used to determine your HIPP eligibility. By signing

below, you are agreeing that the information provided on this form is true and complete to the best of your knowledge.

Signature: ____________________________________________________ Date: _____________________________

Send your completed application to AL HIPP, 3066 Zelda Rd. Box 233 Montgomery, AL 36106, or fax it to 855-357-1130.

If you have any questions, call us toll-free phone at: 1-855-MyALHIPP.

Alabama Health Insurance Premium Payment Application Form

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