Enrollment Questionnaire
Please complete and submit this Enrollment Questionnaire to help speed up access to your benefits.
This
checklist
will help you be prepared to answer all of the questions on the form.
If you need assistance, please
contact us
This information is being submitted via a secured connection. Please see our
privacy policy
for more information.
Member ID :
Please enter the 8-digit GEHA ID number located on your ID card.
View Sample Medical Card to find your Member ID
I don't have my Medical Card yet
Member Name :
If you commonly use a name other than your first name, please enter that here.
Email Address :
Gender :
Male
Female
Date of Birth :
Primary Contact Information
Would you like to provide an alternate address (for a summer home for example)?
Yes
No
Alternate Contact Information
For period of :
to
If you have a summer home or another residence that you normally use for a set part of the year, please provide that information..
In which plan are you enrolling?
Elevate
High Deductible Health Plan
Standard
Elevate Plus
High
Who is enrolling in the plan?
Self Only
Self Plus One
Self Plus Family
Are you married?
Yes
No
What date were you married?
Self Plus One Enrollment – Spouse and Dependent Information
First Name
MI
Last Name
Preferred Name (if applicable)
If you commonly use a name other than your first name, please enter that here.
Date of Birth
Relationship To Member
Disabled
We ask the disabled status of your dependents over the age of 26 in order to comply with the Office of Personnel Management (OPM). We do not need the disabled status for your spouse.
Gender
Social Security Number
The Affordable Care Act requires health insurers to collect Social Security Numbers to report coverage to the Internal Revenue Service.
Yes
No
Family Enrollment - Spouse and Dependent Information
First Name
MI
Last Name
Preferred Name (if applicable)
If you commonly use a name other than your first name, please enter that here.
Date of Birth
Relationship To Member
Disabled
We ask the disabled status of your dependents over the age of 26 in order to comply with the Office of Personnel Management (OPM). We do not need the disabled status for your spouse.
Gender
Social Security Number
The Affordable Care Act requires health insurers to collect Social Security Numbers to report coverage to the Internal Revenue Service.
Yes
No
Remove
Add
Are you or any covered dependent enrolled in another Federal Employees Health Benefits (FEHB) plan?
Yes
No
add information about another family member's FEHB coverage
Are you or any covered dependent enrolled in any other non-federal health insurance plan?
If you or a dependent have any other coverage with which GEHA will need to coordinate benefits, please answer yes and enter the requested information.
Yes
No
add information about another family member's non-Federal health coverage
Have you or any covered dependent filed a claim with Workers' Compensation?
Yes
No
add information about another family member's Workers' Compensation claim
Are you or any covered dependents enrolled in Medicare?
Yes
No
add information about another family member's Medicare enrollment
Questions related to your High Deductible Health Plan plan
As of the first of the new benefit period, will you be covered as a dependent on someone else's tax return?
Yes
No
As of the first of the new benefit period, will you have received VA benefits over the past three (3) months?
Yes
No
As of the first of the new benefit period, are you or your family eligible for TRICARE?
Yes
No
As of the first of the new benefit period, will you or your spouse have a flexible spending account (FSA)?
Yes
No
What kind of FSA do you have?
General Medical FSA
Limited-Purpose FSA
Post-Deductible FSA
other
"First of the new benefit period" is defined as the effective date of the coverage for which you are enrolling
By entering the name below, I certify the information furnished by me is true and correct to the best of my knowledge and belief.
Member Signature :
Date :