Guest Member Application

Todays date: 12/08/2023

Guest membership effective date will be the 15th day following receipt of a completed form. (Retroactive effective dates are not allowed.) Guest membership termination date will be six months or one year following the effective start date. (Refer to selected category under Guest Membership Details below. Termination dates can be sooner per member request based on need. Once enrolled, you will receive a Guest Membership ID card and program materials regarding your Primary Care Physician selection from the Host carrier based on the guest member’s address. If the subscriber’s HMO/POS coverage is cancelled at any time, the Guest membership coverage will be cancelled.