Sena Health Enrollment Form

SENA Health Enrollment Form
Please sign this form and fill in your information, to enroll in this program. Full details can be found below.

As a member on a Arc Mercer Medical Plan, you are eligible for a new benefit provided by SENA Health, LLC (“SENA”), a HIPAA-protected partner of the Arc Mercer Health Plan. This benefit provides Health Coordinators to assist you in effectively navigating the complex healthcare system, helping you find available medical, wellness and clinical providers, and assisting you scheduling of your services with the providers you have selected.

These services are completely voluntary, and are completely free to you.

By signing my name, I am indicating my understanding and acceptance of the eligibility criteria and authorizations as set forth below.

After enrolling, a Health Coordinator will reach out for intake within 48-72 hours.They will be calling from (609) 961-6422.
Name (as on Insurance Card)*

First NameLast Name
Date of Birth*

MonthDayYear
Date
I am a*
Are you currently enrolled in a Arc Mercer Medical Plan or have you recently elected benefits?*

I am currently enrolled in Arc Mercer Medical PlanI have recently elected my benefits and will be effective soonI am not enrolled in Arc Mercer Medical plan and have not elected any benefits
Phone Number*
I agree that SENA Health will have access to my medical records and can retrieve my medical data for coordination and medical reconciliation purposes:*
Signature*

Clear
Should be Empty:

SENA Health Enrollment Form