Enrollment Services PO Box 8868 Wilmington, DE 19899 302.421.3400 Fax 302.421.8948 MEMBER ENROLLMENT / CHANGE APPLICATION Thank you for choosing Highmark Blue Cross Blue Shield Delaware as your
JULY, 2008 2 5.2 Verifying Eligibility Overview Highmark Blue Shield processes over 326,000 medical claims per day. During 2006, it processed over 81 million medical claims. The Company could not have accomplished this without the cooperation of providers, office and medical assistants
Lafayette College 178322 & 178323 Freedom Blue PPO In Network Out Of Network H Eyeglasses or Contact Lenses (Covered every year) Standard eyeglass lenses
First Name MI Last Name Relationship to You? q Child q Step-child q Other* Social Security Number (If no SS#, write N/A) Gender q Male Date of Birth (Month/Day/Year) Dependent Status if over Age 26
employee 1. each time you request benefits, sign section a and complete section b (items 1 - 14) on the reverse side of this form. use a separate benefit request form for each member of the family.
The Impact of Poverty on A Child’s Academic Performance Page 2 The Institute for Public Policy & Economic Development (The Institute) is a partnership of ten colleges and universities in the Scranton/Wilkes-Barre/Hazleton
This summary is intended to highlight the benefits available to you. For detailed information regarding benefits, exclusions and limitations, please refer to your contract.