HOW TO ENROLL - COVENTRY “Kids Only” Plan UTD MEMBER’S BENEFIT FOR 2011 • Complete Materials for the Coventry “Kids Only” coverage: 1. Coventry Enrollment Application – when completing the application, list the child to be covered as the main subscriber or employee. The UTD member’s information does not go on this application. All questions should be answered based upon only the child to be covered. 2. DOE-70 – complete this form with the UTD member’s information. • Submit the application for coverage: 1. By e-mail to [email protected] 2. Or by fax to (877) 559-7709 • Plan coverage and premium information can be downloaded from the UTD web site (www.UTD.org) If you have any questions please call or e-mail the UTDCoventry Enrollment Specialist, Marjorie Jerome, at (954) 3751578 or [email protected]. Enrollment Application (for large group eligible employees) Please PRINT to complete using black ink. Initial all corrections. All questions must be answered. Member Status Change □ New Hire □ Open Enrollment If waiving coverage reason: □ Special Enrollment* □ Benefit change □ Additions □ Waiving coverage □COBRA* *Complete Qualifying Event box below. Effective Date of Coverage Employer / Group Name Employee Information Social Security or HICN Number (required) Sub-Group Number Last Name Benefits Admin Initials First Name M.I. Height Weight Address Apt. City State Zip Code Mailing Address (if different than above) Apt. City State Zip code Home Telephone Number Work Telephone Number ( ( ) Language Preference □ English □ Spanish □ Other Date of Hire E-Mail Address Birth Date Primary Care Physician (First and Last name) Existing Patient? □ Yes (attach proof) □ No Qualifying Event **include legal documentation Event date: □ Marriage** □ Legal Guardianship** . □ Adoption** □ Other . Insurance Co. Name: Coventry Provider ID # (located in provider directory) Dependent Child to age 30 Option Do you want to cover eligible dependents to age 30? □ Yes □ No Other Health Coverage When coverage with Coventry begins, will you or any dependents have any other health coverage? Yes Medicare Coverage Do you or your covered dependents have Medicare coverage? Medicare ID#: Yes Product Selection (required) □ HMO □ POS □ PPO . . . # # # No If “Yes”, please complete the following: Insurance Co. Address: Name(s) Gender □ Male □ Female ) Insurance Co. Telephone #: . No If “Yes” please complete the following: Medicare Part A effective date: Medicare Part B effective date: . Please select one of the following reasons for Medicare coverage: Age Disability ESRD Other Prior Health Coverage Have you been covered by any other health coverage within the last 12 months (or 18 months for late enrollees)? Yes No (If yes, Certificates of Creditable Coverage will be requested.) Family Information For dependent coverage, list each dependent below. Indicate additional dependents on a separate sheet. Except for dependents pursuing a full-time or part-time student status at an accredited institution, college, university, vocational or secondary school, dependents must maintain their primary residence in Coventry’s service area, or the dependent is not eligible for HMO coverage. If dependent is unmarried and age 25, attach proof (a) if student: a letter from registrar’s office certifying current hours enrolled; or (b) if not a student but living in household: proof of legal residence (driver’s license, etc); or (c) disabled: a physician’s certification stating date and degree of disability. The child until the end of the calendar year in which the child turns 30, and meets the following requirements: (a) be unmarried and does not have a dependent of his/her own; (b) be a resident of Florida or a full-time or part-time student; and (c) is not provided coverage as a named subscriber, insured, enrollee, or a covered person under any other group or individual health benefit plan or is not entitled to benefits under Title XVIII of the Social Security Act. ***If a dependent who is eligible for coverage has a different last name than that of the employee, you must attach copies of supporting documentation showing evidence of his/her dependent status (birth certificate, court order for guardianship, marriage certificate, etc.). Social Security or HICN Number (required) Last Name First Name M.I. Height Weight 1 2 3 4 Birth Date Gender Relationship to applicant Primary Care Physician (First and Last Name) □ Male □ Spouse □ Child Existing Patient? □ Yes □ No □ Female □ Dom Prt □ Other Social Security or HICN Number (required) Last Name First Name Birth Date Gender Relationship to applicant Primary Care Physician (First and Last Name) □ Male □ Spouse □ Child Existing Patient? □ Yes □ No □ Female □ Dom Prt □ Other Social Security or HICN Number (required) Dependent Last Name (if different***) First Name Birth Date Gender Relationship to applicant Primary Care Physician (First and Last Name) □ Male □ Spouse □ Child Existing Patient? □ Yes □ No □ Female □ Dom Prt □ Other Social Security or HICN Number (required) Dependent Last Name (if different***) First Name Birth Date Gender □ Male □ Female CHL.CHC.CHP.LG.EMP.APP (4/10) Relationship to applicant Primary Care Physician (First and Last Name) □ Spouse □ Child Existing Patient? □ Yes □ No □ Dom Prt □ Other Coventry Provider ID # (located in provider directory) M.I. Height Weight Coventry Provider ID # (located in provider directory) M.I. Height Weight Coventry Provider ID # (located in provider directory) M.I. Height Weight Coventry Provider ID # (located in provider directory) Coventry Health & Life Insurance Company, Coventry Health Care of Florida, Inc., Coventry Health Plan of Florida, Inc. 1340 Concord Terrace, Sunrise, FL 33323 Item# CHGF1599 Employees and dependents who are or become eligible for premium assistance under the Children’s Health Insurance Program (CHIP) or Medicaid or who lose coverage under CHIP or Medicaid and are otherwise eligible for this plan may enroll in this plan within 60 days of the individual (or a dependent)losing eligibility for the Medicaid or CHIP program or within 60 days of becoming eligible for premium assistance under Medicaid or CHIP even though the timing falls outside an open enrollment period and the employee previously refused employer coverage. Election of Coverage and Authorization I, on behalf of myself and all dependents, authorize any licensed physician, medical practitioner, hospital, clinic, pharmacy, pharmacy benefits manager or other pharmacy related services provider or other medical or medically related facility or provider, insurance company (including Coventry and affiliates), or other organization, institution or person, that has any records or knowledge of the health of me or any dependent, including but not limited to personal information, records concerning physical or mental illness, information relating to autoimmune deficiency syndrome (AIDS), human immunodeficiency virus (HIV), the use of drugs or alcohol or other advice, diagnosis, prognosis, prescription information, care or treatment provided to me or any dependent, to release such information to Coventry or its authorized representatives. I, on behalf of myself and all dependents, hereby provide Coventry with consent to use personally identifiable information for general treatment, underwriting, payment or health care operations, including but not limited to coordination of care, quality assessment, utilization review, fraud detection or accreditation purposes. I understand information obtained with my authorization may be re-disclosed by Coventry as permitted or required by law and in some instances may no longer qualify for protection under Federal and State privacy laws. I understand that my authorization is voluntary and that such information will be used by Coventry for the purpose of evaluating my employer group’s application for health insurance. If personally identifiable information is to be used for any other purpose, Coventry will obtain specific authorization from me and all other dependents as required by applicable law. This authorization is valid from the date signed until revoked by me in writing (which I may do at any time) or such shorter period required by applicable law. Any revocation will not affect the activities of Coventry prior to the date revocation is received by Coventry. I certify that all information and statements furnished by me are true and complete to the best of my knowledge. I understand that any misrepresentation or omission of any information including pre-existing conditions may result in the rescission of my or any dependent’s coverage to the coverage effective date. I understand that I am financially liable for any charges incurred after the effective date until the coverage is rescinded. I hereby acknowledge Coventry’s right to require proof of any dependent’s dependent status. I understand that Coventry does not directly employ any participating providers or facilities. All health care providers and facilities are independent contractors and are not the agents or employees of Coventry. I understand that I and all dependents must comply with the eligibility requirements as stated in the Certificate of Insurance/Certificate of Coverage, or Group Master Contract. The Certificate of Insurance/Certificate of Coverage or “Certificate” can be obtained through (i) the website at www.CHCFlorida.com (ii) by contacting your Group Benefit Administrator, or (iii) by calling the Customer Service Department; for Coventry at 1-866-847-8235 and requesting a hard copy of the Certificate be mailed via U.S. regular mail. Your signature on this application represents acceptance of these delivery options. I understand that any person who knowingly and with intent to injure, defraud, or deceive any insurer, files a statement of claim or an application containing any false, incomplete or misleading information may be guilty of a felony of the third degree. Coventry may rescind coverage of any member who knowingly defrauds Coventry. MY SIGNATURE CERTIFIES THAT I HAVE READ AND AGREE TO THE TERMS AND CONDITIONS OF THIS APPLICATION. X CHL.CHC.CHP.LG.EMP.APP (4/10) Applicant Signature Coventry Health & Life Insurance Company, Coventry Health Care of Florida, Inc., Coventry Health Plan of Florida, Inc. 1340 Concord Terrace, Sunrise, FL 33323 Date Item# CHGF1599 DOE 70 Last Name UTD MEMBER BENEFITS First M.I. Work Location No. Pay Code Employee No. Social Security Number xxx-xx________ Do not write in this box FOR OFFICE USE ONLY! DELETION DEDUCTION CHANGE NEW ACCOUNT Number of Deductions: ___________ Total Amount Per Pay: ___________ Payroll Effective Date: ___________ I hereby give written authorization to the United Teachers of Dade to authorize the School Board of Dade County to deduct by payroll deduction from my salary or to change the amount of the present deduction from my salary, monies for various insurances provided by my union as indicated on this card and any other valid authorization card still in effect. I understand the amount of the deduction could increase/decrease when I authorize policy changes (endorsements) and/or the annual renewal of my policy. I also authorize the UTD to discontinue all or any part of this deduction when the purpose therefore ceases to exist. I also agree to remain a dues-paying member of the United Teachers of Dade for the entire term of the service(s) indicated on this card. Should I breach this agreement, payroll deduction will cease, and any services(s) and/or insurance plan(s) rendered under this card will be terminated. The School Board of Dade County shall be absolved from any and all liability resulting from the collection of these funds. _ REV. 10/27/2009 _______________ ____________________________________ Date Signature FOR OFFICE USE ONLY – PLEASE DO NOT WRITE BELOW THIS LINE! INSURANCE CODE ADD Number of Deductions: _________ INDICATE (X) DELETE CHANGE Total: _______________ TERM OF CONTRACT ANNUAL COST AMOUNT PER PAY PERIOD Payroll Effective Date: _______________