Instructions for Enrollment Forms
Instructions and Checklist for students enrolling, re-enrolling or changing health 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 Form (1 Page)
- Check the box for Blue Cross Blue Shield PPO
- Complete Subscriber Information
- Signature and Date
If you are choosing HMO coverage
- Complete New Subscriber Enrollment Form (1 Page)
- Check the box for Blue Care Network HMO
- Complete Subscriber Information
- Signature and Date
- Complete Primary Care Physician Selection Form (1 Page)
- Your information and your doctor's 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 Form (1 Page)
- Check the box for Blue Cross Blue Shield PPO
- Complete Subscriber Information
- Signature and Date
If you are choosing HMO coverage
- Complete New Subscriber Enrollment Form (1 Page)
- Check the box for Blue Care Network HMO
- Complete Subscriber Information
- Signature and Date
- Complete Primary Care Physician Selection Form (1 Page)
- Your information and your doctor's information
- Signature and Date
Please return all completed paperwork to:
Shanae Pruitt
Scheduling Coordinator
records@med.wayne.edu
Phone: 313-577-3741
Fax: 313-577-9420