HAP HMO Enrollment Application 2026

1. Click ‘Get Form’ to open the HAP HMO Enrollment Application in our editor.
2. Begin by filling out the employer section, including Group ID, Sub-Group ID, Class ID, and Effective Date of Coverage. Ensure all required fields marked in orange are completed.
3. In the applicant section, select whether you are enrolling for HMO or POS. Fill in your Last Name, Legal First Name, Middle Initial, Address, City, State, Zip Code, and Primary Phone.
4. Provide your Birth Date and Date of Hire. List your Personal Care Physician and their PCP Code/NPI. Include details for any dependents you wish to enroll by entering their names and Social Security Numbers.
5. Indicate tobacco use status for yourself and dependents over 18. Complete additional sections regarding other health care coverage if applicable.
6. Finally, review all information for accuracy before signing the application at the bottom. Ensure you date your signature appropriately.

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