| Group number |
Employee's 6-digit employer group number |
| SSN |
Member's 9-digit Social Security number (no hyphens or spaces) |
| Member first name |
Member's first name. May contain only letters, spaces or hyphens.
|
| Member middle initial |
Member's middle initial. Must be a single initial only.
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| Member last name |
Member's last name. May contain only letters, spaces or hyphens. |
Title
|
Member's title, such as Jr, Sr, II, IV, etc. No punctuation.
|
| Gender |
Use the drop-down menu to pick M for male or F for female |
| Date of birth |
Member's date of birth (mm/dd/yyyy) |
| Relationship |
Use the drop-down menu to pick a relationship to the employee: self (contract holder), spouse or child |
| Full-time student? |
Optional field. Due to health care reform, student validation is no longer required.
Use the drop-down menu to select YES if member is full-time student. Leave blank if the member is not a full-time student. |
| School name |
Optional field. Due to health care reform, student validation is no longer required.
Name of the school the full-time student is attending.
|
| Enrollment date |
Optional field. Due to health care reform, student validation is no longer required.
Date the full-time student began full-time status. (mm/dd/yyyy) |
| Address 1 |
Member's mailing address, whether it's a street address, apartment or PO Box. May contain only letters, numbers and spaces. |
| Address 2 |
Continue member's address if they live in Canada or another country. May contain only letters, numbers and spaces. |
| City |
Member's city |
| State |
Member's state (pick the 2-letter abbreviation from the drop-down menu) |
| Zip |
Member's 5-digit zip code |
Phone number
|
Member's 10-digit primary phone number (no hyphens, periods or spaces) |
| Hire date |
The employee's hire date (mm/dd/yyyy). Required for the employee only. |
| Effective date |
The date the employee can start receiving benefits (mm/dd/yyyy) |
| Subgroup |
Priority Health use only – no input needed |
| Class |
Priority Health use only – no input needed |
| MedPlan |
Priority Health use only – no input needed |
| RxPlan |
Priority Health use only – no input needed |
| HSA |
Priority Health use only – no input needed |
| HRA |
Priority Health use only – no input needed |
| HealthbyChoice |
Enter HBC if the member is participating in HealthbyChoiceSM |
| Dental |
Enter DENTAL if the member is selecting dental coverage |
| Vision |
Enter VISION if the member is selecting vision coverage |
| Other benefit |
Identify additional benefits. For information on what types of benefits to enter, contact your sales representative.
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| Employee/spouse type |
Use the drop-down menu to select the choice that best describes the employee or surviving spouse type
|
| Benefit type |
Use the drop-down menu to select the employee's plan |
| Primary Care Provider (PCP) ID # |
Enter the PCP identification number (up to 10 digits) for the member's PCP. You can find this number using Find a Doctor.
(HMO and POS plans: Per our standard procedure, we'll auto assign a PCP if one isn't selected.) |
| Are you a current patient? |
Use the drop-down menu to select YES or NO to indicate if the member is a current patient of the PCP |
Comments
|
Enter additional information for that member, such as an original start date for COBRA coverage. This field is for reference only. |
