Employee Enrollment Form - uat.avmed.org - uat avmed 2026

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4.8 out of 5

273 votes

The document is an Employee Enrollment Form for AvMed health insurance coverage, detailing various plan options, employee and dependent information requirements, and authorization for the release of protected health information (PHI). It includes sections for personal details, coverage selection, and consent for data sharing related to healthcare services. The form emphasizes the importance of accurate information and compliance with legal standards.

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Click ‘Get Form’ to open it in the editor.
Begin by selecting your Coverage Type and Plan Option from the provided choices, such as Employee Only or Family coverage.
Fill in the Employer Information section, including Employer Name and Group/Division number.
Indicate your Employee Work Status (Active or Retired) and provide the Date of Hire and Effective Date of Coverage.
In the Employee Information section, enter your personal details including name, address, Social Security number, and contact information. Don’t forget to select a Primary Care Physician (PCP).
Complete the Dependent Information section if applicable. Provide details for each dependent, including their relationship to you and any necessary documentation for eligibility.
Review the certification statement carefully before signing and dating the form at the bottom.

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Versions	Form popularity	Fillable & printable
2016	4.8 Satisfied (273 Votes)
2014	4.3 Satisfied (60 Votes)

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is the purpose of an enrollment form?

Enrollment forms record whether employees have enrolled in or waived group benefits. For instance, if you have more than 50 full-time employees, you will need this data to complete IRS forms 1094 and 1095, which record health care coverage.

Is AvMed a marketplace plan?

AvMed Entrust Marketplace plans are a lower-cost, subsidy-eligible option. If you qualify for a subsidy, youll see plan details and pricing with the monthly discount.

What is an employee form?

New employee forms are documents an onboarding employee completes for a company. Some forms are required by law, such as tax forms, while others may be for a particular company or position. They help verify the new employee understands company policies, compensation payments and benefits.

What is a benefits enrollment form?

Benefits enrollment, also known as open enrollment or benefits election, refers to the process through which employees choose and sign up for the employee benefits offered by their employer. These benefits often include health insurance, dental insurance, vision insurance, life insurance, retirement plans, and similar.

What happens if an employee misses open enrollment?

Legally, employers are not required to do anything for employees who have missed the open enrollment deadline. In fact, the terms of your benefits plans may prohibit you from making exceptions for employees who do not make benefits elections within a certain time period, such as before the new plan year begins.

filer enrollment

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How many employees does AvMed have?

AvMed is one of Floridas oldest and largest not-for-profit health plans headquartered in Miami, Florida with over 50 years of experience focused on providing quality cost-effective plans and excellent Member services. Members have the support of 400+ employee colleagues and a 35,000 plus strong Provider Network.