NOTE: This may be done on an enrollment form (enclosed with the notice) or on a supplemental
If the individual fails to respond within 60 days, the incorrectly completed form
is not effective.
Among the improperly completed enrollment forms which may establish the application
date are those which the individual:
Signed but failed to answer “yes” or “no.”
Answered “yes” but failed to sign.
Answered both “yes” and “no” and signed or did not sign.
Signed with an unwitnessed mark, with or without answering “yes” or “no.”
If a person writes on an enrollment form “I am already enrolled” or a similar phrase, this means “yes.”
If the person writes “I am a welfare recipient” or any statement constituting an allegation of State buy-in coverage, the office
receiving the qualified or restricted enrollment application will initiate action
to resolve the issue. (See HI 00815.088.)
Enrollment forms returned by mail which have been checked “no,” but are unsigned, are treated and acknowledged as declinations. No further development
will be required merely to obtain a signature.