PCP Subscriber Enrollment/Change Form

PCP Form

What are the changes requested?

(subscriber mark the box for each change you are requesting)

Enroll subscriber (and dependents)

Remove dependent(s) from subscriber account

Update address

Add dependent(s) to existing subscriber account

Change name of subscriber and/or dependent(s)

Other

Subscriber/employee information

Notice: Please complete all information pertinent for medical services at our Kare KONEC freestanding facility or network providers

First Name

Last Name

Medical record number (if known)

TRN

Former name/nickname

Date of birth

Phone

Home Address

Address Line 1

City

Parish

Zip Code

Mailing Address

Address Line 1

City

Parish

Zip Code

Signature

please sign at the bottom of this page in the box below for subscriber signature

Kare KONEC Medical and Affiliates Agreement: As provided under my Employer’s Group Contract, I elect medical benefits & coverage as indicated above on behalf of myself and my eligible dependent(s) as listed above (where applicable) and authorize my employer to deduct from my earnings the contributions required (if any) for the benefits elected. Having elected Medical (including Dental and/or Optical Plan), I authorize kare KONEC and affiliate network providers to have access to, and copies of, all medical, hospital or other institution/agency records relating to the diagnosis, treatment or services provided to me or a covered dependent.. I certify that the above information is correct to the best of my knowledge and confirm that I understand the conditions as stated above.

Signature

Date

Subscriber’s last name*

Subscriber’s medical record (if known)

E. Dependents

Dependent information page(s) Use this page to enroll, remove, or update dependents. Multiple dependent information pages may be used, if space is needed for additional dependents. Sections A–D on the Customer and Subscriber information page are required for all requests.

Repeater Container

Type

Gender

Former name/nickname

Relationship to subscriber

First Name

Medical record number

TRN

Date of birth

Last Name

Has this person ever received services at a Kare KONEC or Affiliate facilities

Additional information

Name(s) of covered dependent(s) that live at a different address than subscriber

Address Line 1

City

Parish

Zip Code

PCP Subscriber Enrollment/Change Form

Company information

What are the changes requested?

Subscriber/employee information

Signature

E. Dependents

Additional information