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Click ‘Get Form’ to open the uhcny630270 001 in the editor.
Begin by filling out Section A, Group Information. Enter the Group Number and Group Name as provided by your employer. Ensure all details are printed clearly using a blue or black ballpoint pen.
Proceed to Section B, Applicant Details. Fill in your personal information including Employee/Subscriber name, Social Security Number, and Date of Birth. Remember to check the appropriate boxes for Gender and Disability Status.
In this section, also provide details about your Primary Care Physician (PCP) including their ID number and name. If you are an existing patient, check 'Yes'.
Complete Section C, Coordination of Benefits. List any prior coverage and ensure that all fields are filled accurately before submitting.
Finally, review all entries for accuracy and completeness before signing at the bottom of the form. Submit within the specified time frame for processing.

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