Sample Enrollment Confirmation Letter Template printable pdf download

Sample Enrollment Confirmation Letter Template

Sample Enrollment Confirmation Letter

SALLY SAMPLE

35 W MAIN ST

ANY TOWN, PA 17815

12/9/2015

POLICY EFFECTIVE DATE: 01/01/2016

TOTAL MONTHLY PREMIUM: $259.58

SUBSIDY AMOUNT: $100.00

MEMBER RESPONSIBILITY AMOUNT: $159.58

MEMBER ID: 1231231231200

Dear Member:

This is a reminder that you are enrolled in the Individual Comprehensive Major Medical Non-Gatekeeper

Preferred Provider Agreement. This Agreement is identified as <Insert Plan Name> (Agreement). You should have

received your <Insert Plan Name> Plan Agreement and identification (ID) card in the mail.

This letter includes details about your effective date and monthly premium. Please keep it with your Agreement.

If the information is correct, you do not need to take action.

For questions about your coverage, please call Member Service. The toll-free number is <Customer Service

Phone>. You can call between 8 a.m. and 8 p.m. EST, Monday through Friday.

If you need help because you have a disability or if English is not your first language, please call <Customer

Service Phone>. Or call TTY at 711 to get free help.

Highmark Individual Markets

Sample Enrollment Confirmation Letter Template