Enrollment & Change Forms
All enrollment & change forms are in a fillable PDF format and can be downloaded. The fillable fields can be completed electronically but all forms must be signed.
Forms should be signed, dated, and can be electronically uploaded using the secure file submission below or can be emailed to email@example.com
or faxed to 800-229-6902.
Interlocal Trust Enrollment Form
Employer Groups must notify Interlocal Trust of status changes that affect eligiblity by submitting an Enrollment & Change form. This form can be completed for new enrollments, status changes, terminations and removing/adding dependents.
This form must be signed by both the Employee and the Employer.
Address/Phone Change Form
An Address Change form can be used to change a subscriber’s address and/or phone number.
This form can be completed by the Employee.
NHRS Annuity Form
For those eligible employees, upon retirement a completed NHRS annuity deduction form is needed to be set up appropriately for billing. Completed forms can be submitted electronically, but Employer Groups must mail a hard copy form to Interlocal Trust.
This form must be signed by both the Retiree and the Employer. This form is for Employer Groups who have Interlocal Trust administer NHRS payments on their behalf.
Notice of Membership Change Form
This form may be used to terminate one or more subscriber contracts from the Employer Group Health Plan.
This form is to be completed only by the Employer.
Harvard Pilgrim Health Care
The following Harvard Pilgrim Health Care forms are for enrolled subscribers and dependents to complete. These forms must be completed & signed by the covered individual and must be mailed to the Harvard Pilgrim address notated on each form (if applicable).
Disabled Dependent Application
For Harvard Pilgrim to verify your dependent’s eligibility as a disabled adult dependent, this form must be completed and returned to Harvard Pilgrim Health Care.
Member Release Authorization
Complete this form to release protected health information. By completing this form the covered individual authorizes Harvard Pilgrim to release health information to a recipient indicated on this form.
Harvard Pilgrim Claims Issue Form
Need assistance with a claims issue? Members should contact the Harvard Pilgrim’s Member Services Department first. If additional assistance is needed, Interlocal Trust can assist and will need the attached form completed.
Notice of Privacy Practices
This notice from Harvard Pilgrim Health Care describes how medical information about you may be used and disclosed and how you can access this information.
To prepare and ensure a smooth transition to our new enrollment & billing platform from Vimly Benefit Solutions for July 1, 2023, we will have an enrollment blackout period from March 27 – April 1.
Please continue to send your enrollment & changes during this time. They will be held until we begin dual processing April 3
Countdown to NHIT Enrollment Blackout Period
Enrollment & Change Form Secure File Submission
Upload your NHIT Enrollment & Change forms via a secure file drop here. Forms will be processed accordingly by Enrollment & Billing.