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.

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.

Primary Contact Information

Would you like to provide an alternate address (for a summer home for example)?


In which plan are you enrolling?
High Deductible Health Plan
Who is enrolling in the plan?

Are you married?     

Are you or any covered dependent enrolled in another Federal Employees Health Benefits (FEHB) plan?

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.
 

Have you or any covered dependent filed a claim with Workers' Compensation?

Are you or any covered dependents enrolled in Medicare?