Enrollment/Change Form_____/_____/_____
New & Existing Groups Effective 1st of the Month ONLY
61 Broadway, Suite 2705, New York, NY 10006
P(888) 313.7277 zF(888) 354.7277 z [email protected]
A. Enrollment/Additions (Choose only one reason in bold)
Medical Dental VisionEverGuard
Reason: Group Open Enrollment
New Hire
Rehire
Status Change (PT to FT) on_____/_____/_____
Involuntary Loss of Coverage_____/_____/_____
Add Dependent Birth on_____/_____/______ Marriage on_____/_____/_____ Adoption (Attach legal document)
Other____________________________
Required Documents (Submit within 30 days of qualifying event):
0DUULDJH&HUWL¿FDWH Spouse w/ different last name z %LUWK&HUWL¿FDWH Dependent w/ different last name, Newborn is added z *XDUGLDQ6WXGHQW9HUL¿FDWLRQ)RUP Enrolling dependent
19 yrs or older z Declaration of Cohabitation & Financial Interdependence Form Enrolling a domestic partner z Note Additional Documents may be required
B. Changes (Check all that apply)
New Name
New Address
Other_______________________ Date of Change (MM/DD/YY)________________________
C. Cancel Coverage (Check all that apply)
Medical
Reason:
Dental
Vision
EverGuard Cancel Dependents listed below in Section G
Left Employer
Hours Reduction Other___________________________________________
D. Waiving Coverage (Complete sections D, E, L and M) Check off plan(s) you are waiving:
By waiving coverage, I understand I will not be able to enroll without a qualifying event or until my employer’s next open enrollment.
Reason:
Covered by other plan
Not interested - no other coverage
Reason:
Covered by other plan
Not interested - no other coverage
Reason:
Covered by other plan
Not interested - no other coverage
Reason:
Covered by other plan
Not interested - no other coverage
Current Medical Coverage:
Name of Insurer
Name of Policyholder
Policy ID #
Effective Date
Medical
Dental
Vision
EverGuard
Term Date
E. Employee Information All information must be provided for enrollment.
Are you an owner of the company?
Company Name
Yes No
Date of Hire
Actively at Work
Retired
Hrs. Worked Per Week
Employee Name (Last, First, Middle Initial - Please Print)
Social Security #
Street Address
Apartment #
City
Home/Cell Phone
E-mail
Not Active
COBRA
Male
Female
State
Zip
Date of Birth (MM/DD/YYYY)
Single Married Divorced
Domestic Partner Widowed
Initial Enrollment Only,I\RXDUHVHOHFWLQJWKH2[IRUG*ROG(32RU6LOYHUSODQIRUWKH¿UVWWLPHSOHDVHVHOHFWDSULPDU\FDUHSURYLGHU,IQR3&3LV
selected one will be assigned to you or you must contact the carrier directly to update your PCP.
Dr. Name:
ID #:
F. Dependent Information
List all dependents
Dep # 1 (Last, First, Middle Initial)
Male Female
Date of Birth (MM/DD/YYYY
Relationship: Spouse Domestic Partner Child
Domestic Partner Child Yes No
Verify Dependent:* (If different last name) Yes No 8QYHUL¿DEOH
Dr. Name:
ID #:
Dep # 2 (Last, First, Middle Initial)
Male Female
Date of Birth (MM/DD/YYYY)
Relationship: Spouse Domestic Partner Child
Domestic Partner Child Yes No
Verify Dependent:* (If different last name) Yes No 8QYHUL¿DEOH
Dr. Name:
ID #:
Dep # 3 (Last, First, Middle Initial)
Male Female
Date of Birth (MM/DD/YYYY)
Relationship: Spouse Domestic Partner Child
Domestic Partner Child Yes No
Verify Dependent:* (If different last name) Yes No 8QYHUL¿DEOH
Dr. Name:
ID #:
Social Security #
Social Security #
Social Security #
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Employee Name (Please Print)
Company Name
G. Type of Medical Coverage
Employee Only
Employee and Spouse
Employee and Child(ren)
Family
Domestic Partner
H. Medical Plan Options
CareConnect (CC)
To enroll in a CareConnect plan, employees must live
or work in the following counties; Nassau, Suffolk,
Manhattan, Brooklyn, Queens, Bronx, Richmond and
Westchester
Oxford (OXHP)
Health Republic (HRI)
To enroll in a Health Republic plan, employees must
live in New York or New Jersey
The Oxford Liberty Gold EPO 30/60 & Oxford Liberty Silver EPO
25/50 are gated plans and require PCP referral to see a specialist
Platinum
CareConnect Standard Platinum EPO
Health Republic TotalFreedom Platinum PPO N/A
Health Republic EssentialCare Platinum EPO
Health Republic PrimarySelect Platinum EPO
Gold
CareConnect Tradition Gold Copay EPO
Health Republic PrimarySelect Gold EPO
Oxford Liberty Gold EPO 30/60
Silver
CareConnect Tradition Silver EPO 40/60 HRx Health Republic PrimarySelect Silver EPO
CareConnect Tradition Silver EPO HSA 100%
Oxford Liberty Silver PPO 40/70
Oxford Liberty Silver EPO 40/70
Oxford Liberty Silver EPO 25/50
Bronze
CareConnect Standard Bronze EPO
Health Republic EssentialCare Bronze EPO
CareConnect Tradition Bronze EPO HSA 70% HSA 50%
Oxford Liberty Bronze EPO HSA 80%
I. Dental Plan Options If your employer is offering Dental Coverage, please indicate the coverage(s) desired. Effective date 1st of the month only.
Managed DentalGuard (DMO)
DentalGuard Preferrred Plus (PPO)
Employee Only
DentalGuard Preferred (PPO)
Managed DentalGuard Plus (DMO)
Managed DentalGuard Child Essential (Pediatric Only)
Employee and Spouse Employee and Child(ren)
Family
Domestic Partner
Select a Dental Facility ID # at initial enrollment only for DMO Coverage:
Employee
Spouse/Domestic Partner
Dep 1
Dep 2
Dep 3
J. Vision Plan Option This is a 24 month contract based on your employer’s effective date. Coverage can only be cancelled at the completion of 2
years or if all HealthPass coverage is cancelled. Effective date 1st of the month only.
I am electing VisionGuard
Employee Only
Employee and Spouse
Employee and Child(ren)
Family
Domestic Partner
K. EverGuard Plan Options YRXPD\RQO\HOHFWWKHFRYHUDJHOHYHORIIHUHGE\\RXUHPSOR\HU,IHOHFWLQJFRYHUDJHSOHDVHLQGLFDWHEHQH¿FLDU\LHV$YDLODEOH
to employees only (no dependents)
I am electing EverGuard
I am electing EverGuard Plus
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1.
2.
L. Employee Signature Electronic signatures are not valid this form must be signed and dated by the employee.
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UHJXODWLRQVWKHUHLQVSHFL¿HG,FHUWLI\WKDW,DPDFWLYHO\DWZRUNDPLQLPXPRIKRXUVSHUZHHNDQGZLOOQRWLI\+HDOWK3DVVLIP\HPSOR\PHQWVWDWXVFKDQJHV,HOHFWWRHQUROOP\VHOIDQGWKHIDPLO\
members indicated on this form with the medical and dental plans and primary care provider as indicated on this form. I certify that all dependents listed on this form are eligible for coverage under the
terms of the plan documents. I agree to notify my employer within 30 days when such eligibility ceases. I understand the medical or dental plans have no liability to provide coverage for ineligible
dependents. On behalf of myself and all family members, I hereby authorize all physicians, nurses, hospitals and other providers who or which have at any time, either before or after we became covered
by the health insurance company, provided any diagnosis, treatment or any other service to any of us, to furnish the insurance companies or their authorized representative all information and records
relating thereto. A photocopy or digital image of this authorization shall be considered as valid as the original. I understand that the Participating Providers, if any, do not necessarily include all types of
doctors or providers.
If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance coverage, you may in the future be able to enroll yourself and your dependents,
provided that you request enrollment within 30 days after your other coverage ends. See edibility guidelines. In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement
for adoptions, you may be able to enroll yourself and your dependents, provided that your request enrolment within 30 days after the marriage, birth, adoption or placement for adoption. If I am required to
contribute premium toward my coverage, I hereby authorize my employer to deduct such contributions in advance from wages due me and remit same to HealthPass. The subscriber is responsible for
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application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact materiel thereto, commits a fraudulent
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I have carefully read this section and certify that all information provided on this form is true and complete to the best of my knowledge.
Employee Signature
M. Employer Signature
Date
Electronic signatures are not valid. This form must be signed and dated by an authorized company representative.