LifeWise Health Plan of
WA - Online
Application
Apply for coverage from LifeWise
of Washington
Washington Std. Health Questionnaire | LifeWise
of Washington Enrollment Form
Application Process and Forms
To apply for any of the LifeWise of Washington individual
medical plans, please complete the following steps:
- Fill out the Application (one per
family)
Click
here to download the LifeWise of Washington
Individual/Family Enrollment Application. Print the
application and fill it out completely.
- Fill out the Questionnaire (one
for each person to be covered)
Click
here to download the Standard Health
Questionnaire for Washington State. Print and complete
the questionnaire for each person
to be covered on the plan. Please refer to Completing
the Health Questionnaire to determine
if this applies.
- Provide Proof of Washington State Residency
To be eligible to purchase this plan you must be a
Washington state resident.
A photocopy of one of the following must accompany
your application to prove residency:
- Valid Washington State Driver's License or Identification
Card
- Washington State Voter Registration Card
- Current Utility Bill in your name, including
address
- Provide Certificate of Creditable Coverage
(if available)
Please refer to Credit
for Prior Coverage & HIPAA Eligibility
for more information. Please note, if you do not have
your Certificate of Creditable Coverage at the time
of application, please submit your application anyway.
Credit for pre-existing condition waiting periods
will be credited upon receipt of your Certificate
of Creditable Coverage by LifeWise of Washington.
- Do not Send a Payment
Please do not send a rate payment with your application.
You will receive a statement from LifeWise of Washington
upon acceptance of your application.
- Send all Enrollment Materials to:
CDA Insurance Services
P.O. Box 26540
Eugene, OR 97402
Please note: LifeWise of Washington requires
all COMPLETED enrollment materials to
be postmarked to their office on or before the 20th of
the month for a 1st of the month effective date. For a
15th of the month effective date, the application must
be postmarked by the 5th. Incomplete enrollments may cause
delays in the effective date of your coverage. Please
refer to the checklist on the application to avoid delays.
For Example: If you wanted your medical
insurance coverage to begin on April 1, you would need
to send all of the required, completed enrollment material
to LifeWise of Washington postmarked on or before March
20.
|
Asuris
NW Health