Providence Health Plan Out-of-Area Dependent Enrollment Form Instructions
This form contains 23 fields organized into 5 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Employer Information | ||
| Employer Name | Text |
Enter the full name of the employer.
|
| Group Number | Text |
Enter the group number for the employer's plan.
|
| First Dependent Information | ||
| First Dependent Name | Text |
Enter the full name of the first dependent.
|
| First Dependent Birthdate | Date |
Enter the birthdate of the first dependent.
|
| First Dependent Address | Text |
Enter the street address of the first dependent.
|
| First Dependent City | Text |
Enter the city of residence for the first dependent.
|
| First Dependent State | Text |
Enter the state of residence for the first dependent.
|
| First Dependent Zip | Text |
Enter the postal code for the first dependent.
|
| First Dependent Member ID | Text |
Enter the member identification number for the first dependent.
|
| Requested Effective Date | ||
| Requested Effective Date | Date |
Provide the effective date for the out-of-area dependent coverage if it differs from the first of the month following the receipt of this form.
|
| Second Dependent Information | ||
| Second Dependent's Name | Text |
Enter the full name of the second dependent.
|
| Second Dependent's Birthdate | Date |
Enter the birthdate of the second dependent.
|
| Second Dependent's Address | Text |
Enter the street address of the second dependent.
|
| Second Dependent's City | Text |
Enter the city of the second dependent's address.
|
| Second Dependent's State | Text |
Enter the state of the second dependent's address.
|
| Second Dependent's Zip Code | Text |
Enter the zip code of the second dependent's address.
|
| Second Dependent's Member ID Number | Text |
Enter the member identification number for the second dependent.
|
| Subscriber Information | ||
| Subscriber's Name | Text |
Enter the full legal name of the subscriber.
|
| Subscriber's Address | Text |
Enter the complete street address of the subscriber.
|
| City | Text |
Enter the city of the subscriber's address.
|
| State | Text |
Enter the state of the subscriber's address, typically as a two-letter abbreviation.
|
| Zip Code | Text |
Enter the zip code of the subscriber's address.
|
| Subscriber Member ID No. | Text |
Enter the subscriber's member identification number.
|