Oasis Health Care: Enroll New Member

Enroll New Member

Please use this web form to:

	Enroll, reinstate or terminate a subscriber		Add or delete a dependent
Change coverage from Individual to Family or Vice-Versa

To change address or name, or request a replacement ID card, please use this form instead. Messages are retrieved every business day between the hours of 8:00 a.m. and 5:00 p.m. Eastern Time.

Reason for Submission:

New Enrollment	Reinstatement
Termination	Change from Individual to Family or Vice-Versa
Add Spouse	Delete Spouse
Add Child	Delete Child

Subscriber Information: (all fields are required)
Last Name:   First Name:   MI:
Address: Street:
City:   State:   Zip:

Date of Birth: Month:   Day:   Year:   SSN (no hyphens):
Sex: Male Female   Marital Status: Single Married   Coverage: Individual Family

Dependent Information: List below all family members to be added or dropped
1. Last Name:   First Name:   MI:
Date of Birth: Month:   Day:   Year:    Relationship:     Fulltime Student?   Action: Add Delete

2. Last Name:   First Name:   MI:
Date of Birth: Month:   Day:   Year:    Relationship:     Fulltime Student?   Action: Add Delete

3. Last Name:   First Name:   MI:
Date of Birth: Month:   Day:   Year:    Relationship:     Fulltime Student?   Action: Add Delete

4. Last Name:   First Name:   MI:
Date of Birth: Month:   Day:   Year:    Relationship:     Fulltime Student?   Action: Add Delete

Spouse Information: If spouse has other Medical Insurance, please answer the following:
Last Name:   First Name:   MI:

SSN (no hyphens):    Employment Status: Employed   Not Employed   Retired
Spouse's Employer:
Street:
City:   State:   Zip:

Spouse's Carrier:
Street:
City:   State:   Zip:
Spouse's Policy Number:    Effective Date:

Submitter Information:
Name of Person Submitting Form:     Position:
Company:    Date:

Questions?

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