Neighborhood Health Plan Member Enrollment Application

Please complete this form to enroll in Neighborhood Health Plan with NASRO. * = Required

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Subscriber Information

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jane@doe.com

Subscriber PCP and Site Information

If the Primary Care Physician (PCP) you choose is not in the NHP network, one will be selected for you. You may change your PCP assignment at any time.


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Group Coverage

In addition to NHP, my spouse or children are covered by a health plan offered by:






About Dependent Spouse

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About Dependent Child(ren)
About Dependent Child #1

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Signature
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Acknowledgement Statement
Acknowledgement: The information supplied on this form is true and complete. I assign benefits to Neighborhood Health Plan (NHP) for the cost of services when the liability for payment is the responsibility of another plan/HMO, worker’s compensation plan or other coverage. I (we) agree that NHP and its affiliated Health Care Providers, may obtain or release my (our) medical information including medical records, medical coverage available or other medical data for the purposes of administering benefits, evaluating medical care provided, conducting quality assurance reviews and analysis, conducting medical research, and/or as required by law. I (we) understand that for NHP coverage to be in effect when medical care supplies are obtained, all care and supplies must be authorized and provided by participating care physicians (as listed above).