Enrollment/Change Form - Professional Group Plans
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 # V1of1 4.15 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 6HOHFWXSWRWZREHQH¿FLDULHV,QGLFDWHWKHSHUFHQWRIOLIHLQVXUDQFHSURFHHGVIRUHDFKEHQH¿FLDU\0XVWWRWDO %HQH¿FLDU\1DPH5HODWLRQ3HUFHQW%HQH¿FLDU\1DPH5HODWLRQ3HUFHQW 1. 2. L. Employee Signature Electronic signatures are not valid this form must be signed and dated by the employee. ,KHUHE\DSSO\IRUWKHKHDOWKLQVXUDQFHFRPSDQ\DQGEHQH¿WSODQVVHOHFWHGXQGHUVWDQGLQJDOOEHQH¿WVDQGFRYHUDJHDVVSHFL¿HGLQWKHHQUROOPHQWPDWHULDOVDQGDJUHHLQJWRDELGHE\DOOWKHUXOHVDQG 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 WKHWRWDOFRVWRIFDUHUHFHLYHGRUIRUGUXJVSXUFKDVHGZKLFKDUHQRWDXWKRUL]HGE\WKHSODQ³$Q\SHUVRQZKRNQRZLQJO\DQGZLWKLQWHQWWRGHIUDXGDQ\LQVXUDQFHFRPSDQ\RURWKHUSHUVRQ¿OHVDQ 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 LQVXUDQFHDFWZKLFKLVDFULPHDQGVKDOODOVREHVXEMHFWWRFLYLOSHQDOW\QRWWRH[FHHG¿YHWKRXVDQGGROODUVDQGWKHVWDWHGYDOXHRIWKHFODLPIRUHDFKVXFKYLRODWLRQ´ 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.
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