Please complete a separate application for each family member who will be residing outside of your state.
(Note: There are 21 states that do not participate in this program: Alabama, Alaska, Idaho, Iowa, Kansas, Mississippi, Montana, Nebraska, North Dakota, Oregon, Rhode Island, South Carolina, South Dakota, Tennessee, Vermont, Utah, Virgin Islands, Washington, Wyoming, West Virginia, and Puerto Rico.)
Required field.
Part 1: Subscriber Information:
First name
Last name
Street
City
State
Zip Code
Home telephone
Work telephone
Social security number
Sex
Male
Female
Date of birth
Martial Status
Single
Married
Divorced
Widowed
Separated
Domestic Partner
Group number
Subscriber ID number
Employment Status
Active
Retired
Email address
Part 2: Guest Information:
Relationship to subscriber
Self
Spouse
Dependent
Domestic Partner
First name
Last name
Street address when away from home
(Note: College students please provide dorm and room number, or P.O. Box.)
City
County
State
(Note: Guest Memberships are not available in Alabama, Alaska, Idaho, Iowa, Kansas, Michigan, Mississippi, Montana, Nebraska, North Carolina, North Dakota, Oregon, Puerto Rico, Rhode Island, South Carolina, South Dakota, Tennessee, Utah, Vermont, West Virginia, Washington and Wyoming.)
Zip Code
Telephone number when away from home
Social security number
Sex
Male
Female
Date of birth
Martial Status
Single
Married
Divorced
Widowed
Separated
Domestic Partner
Name of Primary Care Physician in new area (if known)
Medicare
Yes
No
Part 3: Coverage Request:
Period of Coverage (90-day minimum)
Start
End
Type of Request
New Request
Renewal
Type of guest service
Families apart (Spouse or dependent that does not reside in your state for 90 days or more)
Student (Dependent of subscriber that does not reside in your state for 90 days or more)
Long-term traveler (Subscriber, spouse or dependent that does not reside in your state for 90 to 180 days)
Part 4: Sign off for AFHC Guest Application:
I hereby certify that all information stated in Sections A and B on the front of this application is truthful and correct to the best of my knowledge. I acknowledge that the benefit program providing coverage to myself or eligible dependents as Guest Members of the Host HMO may vary from the benefit program at my Home HMO. I understand that as a Guest Member the Host HMO benefit program's scope and levels of coverage apply. (This does not apply to GM, members receiving home benefits).
I hereby authorize my Home HMO and the Host HMO, identified on the front of this application, to exchange medical information about me.
Required field.
