Instructions for Enrollment Forms

Instructions and Checklist for students enrolling, re-enrolling or changing coverage

Are you enrolling in WSU School of Medicine group health insurance for the first time?

If you are choosing PPO coverage

  • Complete New Subscriber Enrollment (1 Page)
  • Check box for Blue Cross Blue Shield PPO
  • Complete Subscriber Information
  • Signature and Date
     

If you are choosing HMO coverage

  • Complete New Subscriber Enrollment (1 Page)
  • Check box for Blue Care Network HMO
  • Complete Subscriber Information
  • Signature and Date
  • Complete Primary Care Physician Selection Form (1 Page)
  • Your information, your Doctor information
  • Signature and Date
     

Are you currently on WSU School of Medicine group health insurance and you are re-enrolling or changing coverage?

If you are choosing PPO coverage

  • Complete New Subscriber Enrollment (1 Page)
  • Check box for Blue Cross Blue Shield PPO
  • Complete Subscriber Information
  • Signature and Date

If you are choosing HMO coverage

  • Complete New Subscriber Enrollment (1 Page)
  • Check box for Blue Care Network HMO
  • Complete Subscriber Information
  • Signature and Date
  • Complete Primary Care Physician Selection Form
  • Your information, your Doctor information
  • Signature and Date
     

Please return all completed paperwork to:

Kiara Scott
Coordinator for Affiliation Agreements & Heath Insurance
records@med.wayne.edu
Phone: 313-577-1466
Fax: 313-577-9420