Enrollment Forms

Before You Enroll

If your child qualifies for Healthy Kids Silver or Buy-In, here are some documents that will be helpful to you. All of these documents are included in the enrollment packet that is mailed to you.

HEALTHY KIDS SILVER

Welcome Letter 

This letter gives you an overview of your child’s coverage and introduces you to the Healthy Kids Silver program. It also includes helpful contact information and payment information.

Member Handbook
This includes a listing of Primary Care Providers (PCPs) for the Healthy Kids Silver program as well as general benefit information.

Healthy Kids Silver Handbook Insert
This insert includes brief information about the Healthy Kids Silver tiered co-payments, prescription drugs and vision care.

Healthy Kids Silver Enrollment Form
Use this form to enroll your child in the Healthy Kids Silver program. Please make sure you write in a PCP ID number for each child and send in your first month’s payment with the form.

Healthy Kids Silver Automatic Premium Withdrawal Form
Use this form to enroll in our Automatic Premium Withdrawal plan to have your payments automatically deducted out of your bank account each month.

HEALTHY KIDS BUY-IN

Welcome Letter 

This letter gives you an overview of your child’s coverage and introduces you to the Healthy Kids Buy-In program. It also includes helpful contact information and payment information.

Member Handbook
This includes a listing of Primary Care Providers (PCPs) for the Healthy Kids Buy-In program as well as general benefit information.

Healthy Kids Buy-In Handbook Insert
This insert includes brief information about the Healthy Kids Buy-In co-payments, prescription drugs and vision care.

Healthy Kids Buy-In Enrollment Form & Payment Policy
Use this form to enroll your child in the Healthy Kids Buy-In program. Please make sure you write in a PCP ID number for each child and review and sign the Healthy Kids Buy-In Payment Policy. 

Healthy Kids Buy-In Automatic Premium Withdrawal Form
Use this form to enroll in our Automatic Premium Withdrawal plan to have your payments automatically deducted out of your bank account each month.

After You Enroll

If your child is enrolled in Healthy Kids Silver or Buy-In, here are some documents that will be helpful to you.

Medical

Harvard Pilgrim Questions & Answers Sheet
This sheet provides answers to common questions about Harvard Pilgrim Health Care.

Healthy Kids Silver Summary of Benefits
This is a summary of the cost sharing for the Healthy Kids Silver program.

Healthy Kids Silver Evidence of Coverage
This is a detailed description of the covered medical benefits for the Healthy Kids Silver program effective July 1, 2010.

Healthy Kids Buy-In Summary of Benefits 

This is a summary of the cost sharing for the Healthy Kids Buy-In program.

Healthy Kids Buy-In Evidence of Coverage 

This is a detailed description of the covered medical benefits for the Healthy Kids Buy-In program effective July 1, 2010.

Dental 

Healthy Kids Silver Summary of Dental Benefits
This chart is a summary of dental coverage for the Healthy Kids Silver program.

Healthy Kids Buy-In Summary of Dental Benefits
This chart is a summary of dental coverage for the Healthy Kids Buy-in program.

Healthy Kids Silver & Buy-In Dental Plan Description
This is a detailed description of the covered dental benefits for the Healthy Kids Silver and Buy-In programs.

Additional Questions

If you have additional questions about your coverage, contact:

Harvard Pilgrim Health Care

1-888-333-4742
www.harvardpilgrim.org

Northeast Delta Dental
1-800-832-5700 or 603-223-1234
www.nedelta.com