Enrollment/change Form Page 2
ADVERTISEMENT
1
2
3*Applicant Name: ________________________________________ (required)
Add
*Last Name
*First Name
MI
Delete
*Gender
*Relationship
Disabled
*Birthdate
*Social Security Number
Male
Spouse
Disabled
Female
Child
Tobacco Use In Last 6 Months?
Primary Care Provider
☐
☐
Other __________________
Yes
No
PCP#:
PCP Name:
Add
*Last Name
*First Name
MI
Delete
*Gender
*Relationship
Disabled
*Birthdate
*Social Security Number
Male
Spouse
Disabled
Female
Child
Tobacco Use In Last 6 Months?
Primary Care Provider
☐
☐
Other __________________
Yes
No
PCP#:
PCP Name:
Add
*Last Name
*First Name
MI
Delete
*Gender
*Relationship
Disabled
*Birthdate
*Social Security Number
Male
Spouse
Disabled
Female
Child
Tobacco Use In Last 6 Months?
Primary Care Provider
☐
☐
Other __________________
Yes
No
PCP#:
PCP Name:
D
OTHER MEDICAL AND/OR PHARMACY COVERAGE INFORMATION
☐
Yes
When coverage with Coventry Health Care of the Carolinas, Inc. begins, will you or any of your family members have any
other medical insurance coverage? If you answered yes, please complete below.
☐
No
☐
☐
☐
☐
☐
☐
☐
COVERAGE TYPE:
Group Policy
Individual Policy
Medicare
Pharmacy
Medicaid
Tricare
Other __________________
Other Insurance Company Name
Policy Holder Name
Covered Dependents
Relationship
Gender
Birthdate
Effective Date of Other Insurance
Spouse
Child
Male
Other _______________
Female
Other Insurance Company Name
Policy Holder Name
Covered Dependents
Relationship
Gender
Birthdate
Effective Date of Other Insurance
Spouse
Child
Male
Other _______________
Female
Medicare Information
☐
☐
Dependent's Last Name
Reason for Medicare Eligibility
Subscriber or
Dependent
☐
Over 65
Effective Date Of:
Dependent's First Name
MI
☐
Disabled
Part A
☐
Kidney Disease (ESRD)
☐
ALS (Lou Gehrig's Disease)
Part B
Medicare #
Part D
NC ENROLL 2016
2 of 3
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical