PEIA Comprehensive Care Partnership (CCP) Program Enrollment Form
First / Last name
Address
Daytime Phone
Email address
PEIA ID Number:
Insurance Effective Date
MM
/
DD
/
YYYY
To enroll online, go to
www.wvpeia.com
and click on the green
“Manage My Benefits”
button in the upper right corner, register on the site or use your existing credentials to log-in and choose your CCP. If you do not have online access, you may complete this form.
Policy Details
Covered Individuals – PPB Plan A, B & D
(Only individuals listed below will be enrolled)
Relationship to Policyholder
(Self, Spouse, Child)
CCP Location
Facility
Please select
New River Health
Please select
Date
of
Birth:
MM
/
DD
/
YYYY
Add another Individual
PEIA’s CCP Program requires the member’s active participation and program compliance.
I agree that the above-listed persons enrolled on my PEIA PPB Plan coverage will participate in the CCP program at the above-listed health care provider. I agree that I (we) will abide by the rules, policies and restrictions of the CCP program (the member agreement is available on-line or by calling customer service). I understand that if I (we) do not abide by the rules, policies and restrictions of the CCP program, I (we) may be dis-enrolled from the program by the CCP.
Signature
Clear
Date
MM
/
DD
/
YYYY
Please return this form to:
Public Employees Insurance Agency, Attn: CCP, 601 57th St., SE, Suite 2, Charleston, WV 25304-2345 or Fax to 1-877-233- 4295
. Coverage in the CCP will be effective on the first day of the month following receipt of your enrollment form, if received before the 25th of the month.
Verification
SUBMIT FORM
Please wait...
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20