• NON-MEDICARE HEALTH APPLICATION

  • A. Personal Information

  • Gender*
  • Status*
  • Date of Birth:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • B. Reason For Application

  • Reason for Application*
  • Effective Date:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Add Dependents Due To: *Note: Qualifying Event Documentation Is Required
  • Cancel Dependents Due To:

  • C. Health Care Coverage Choices

  • Coverage is for:*
  • Are you eligible for Double State Share?

  • Spousal Coordination of Benefits (SCOB): If you have selected Individual & Spouse or Family Coverage, you MUST complete the SCOB Form upon initial enrollment, anytime enrollment or insurance status changes and each year during Open Enrollment. The SCOB Policy and electronic form can be found at https://www.delawarepensions.com.

  • Healthcare Coverage Choice*

  • D. Eligible Dependents to be Covered/Primary Care Physician Selection

  • Personal Information

  • If more space is needed to list more than 8 dependents, please use a separate form and attach it to this application.

    You can also contact our office at 302-739-4208 or 800-722-7300.

  • Spousal Information

  • Reason for Spouse Information
  • Birth Date:*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Dependent #1 Information

  • Dependent #1
  • Status
  • Gender*
  • Birth Date:*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Dependent #2 Information

  • Dependent #2
  • Status:
  • Gender:*
  • Birth Date:*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Dependent #3 Information

  • Dependent #3
  • Status:
  • Gender:*
  • Birth Date:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • *If you choose Aetna HMO coverage, you MUST include an in-network primary care physician ID, for yourself, spouse and all eligible dependents.

  • Dependent #4 Information

  • Dependent #4:
  • Status:
  • Gender:*
  • Birth Date:*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Dependent #5 Information

  • Dependent #5:
  • Status:
  • Gender:*
  • Birth Date:
     - -
    2 digit month, 2 digit day, 4 digit year

  • Dependent #6 Information

  • Dependent #6:
  • Status:
  • Gender:*
  • Birth Date:*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Dependent #7 Information

  • Dependent #7:
  • Status:
  • Gender:*
  • Birth Date:*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Dependent #8 Information

  • Dependent #8:
  • Status:
  • Gender:*
  • Birth Date:*
     - -
    2 digit month, 2 digit day, 4 digit year

  • E. Terms of Agreement

  • I understand that: 1) Rights to service are subject to acceptance of this application and to the terms and conditions specified in the present contract and any future contract between my employer, association and Highmark Delaware or Aetna. 2) I certify that all representations and information supplied by me are true. My coverage shall be void if any or part of this application is false or incomplete. 3) I authorize my employer, as my agent, if applicable to collect the premiums by payroll deduction or otherwise, for remittance to Highmark Delaware or Aetna, with the understanding that payment will not be complete until actually received. 4) I, on behalf of myself and my covered dependents, authorize any physician, hospital or any other health care provider to release information available to them concerning any diagnosis, treatment or other health care services they render to me or my covered dependents its designee for purposes reasonably related to this contract. 5) I, on behalf of myself and my covered dependents, authorize Highmark Delaware or Aetna to release appropriate demographic information, diagnostic and medical conditions to other persons, entities or organizations for audits, claims processing, coordination of benefits, disease management programs, member satisfaction surveys, other party liability, utilization review, case management, quality improvement and assurance and other reasonably related purposes for the administration of this contract or as required by law.
  • I ELECT to participate in the State Health Insurance and agree to the above terms.
    This is a binding election.
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • I REFUSE to participate in the State Health Insurance.
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: