Special Needs Health Plan Post-Enrollment Verification Form
Please complete this form to verify your post-enrollment details for your special needs health plan.
Full Name of Enrollee/Member
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Health Plan Name
*
Enrollment Status
*
Active
Pending
Inactive
Have you received confirmation of your coverage?
*
Yes
No
Primary Care Provider or Care Coordinator Information
Have you received your plan documents?
*
Yes, all documents
Some documents
No documents received
Do you understand how to access the provider network?
*
Yes
No
Not sure
Are you experiencing any issues accessing medications or services?
Preferred communication method
Please Select
Phone
Email
Mail
Text message
Submit Verification
Should be Empty: