Instructions. 1. Your employer will complete section A. 2. Complete sections B through F.
|
|
|
- Alexis Page
- 5 years ago
- Views:
Transcription
1 Instructions 1. Your employer will complete section A. 2. Complete sections B through. 3. If you are electing medical, complete the section entitled EDICAL OPTIONS. 4. Read the information on the back of the enrollment/change form. 5. Sign and date the enrollment/change. We look forward to having you as our customer. CAT. #EW08873
2 Employer: Complete Section A Employee: Complete Section B- Enrollment/Change orm A OPEN ENROLL CHANGE NEW ENROLL REINSTATE B SINGLE ARRIED / / SEPARATED DIVORCED WIDOWED EECTIVE DATE O CHANGE ADD/CHANGE/CANCELLATION (/DD/CCYY) / / EPLOYER NAE Kenai Drilling Limited Administered by Cigna Health and Life Insurance Company DATE O HIRE (/DD/CCYY) / / PLAN NUBER SUBGROUP TYPE O CHANGE Add (s) * Demographics PCP Change Retirement CLASS * List Name(s) in Section C COBRA Continuation Other Qualifying Event Date: / / C EPLOYEE NAE (Last) (irst) SOCIAL SECURITY NUBER - - EPLOYEE DATE O BIRTH (/DD/CCYY) HOE PHONE EAIL ADDRESS / / ( ) ADDRESS (Street) (City) (State) (Zip Code) YES, I WOULD LIKE COVERAGE OR YSEL AND Y DEPENDENTS. (Specify last name if different from yours) Employee Last Name irst Name Social Security Number Date of Birth (/DD/CCYY) Gender H e i g h t W e I g h t ADDITIONAL INORATION- * DEPENDENTS If totally disabled prior to age 26, attach proof of disability for eligibility review. s are covered under the medical plan to age 26. Proof of student status may be required for dental and/or vision coverage. **PCP ID is required when the edical Option selected below is Cigna Sureit. If a PCP is not selected during enrollment one will be assigned. Otherwise PCP is optional. D EDICAL OPTIONS: Open Access Plus/ OAP IN Open Access Plus/ OAP Open Access Plus/ HSA Coverage Selection ed ed ed ed ed ull- Time Student? Decline Coverage CAT. #EW08873
3 E OTHER HEALTHCARE COVERAGE: Do you or your dependents have other health insurance under a group plan, HO, or edicare? If yes, please provide the following: EDICARE OTHER INSURANCE NAE O PERSON COVERED SOCIAL SECURITY NUBER EECTIVE DATE Part A Part B EDICAID CARRIER - - / / - - / / The information provided above is true and correct to the best of my knowledge, and I accept the provisions on the reverse side of this form which I have read and understand. By my signature below, I acknowledge that I have read and understand the disclosure in this Enrollment/Change orm. I authorize the required payroll deduction for contributory benefits. I also represent that all information shown on this Enrollment/Change orm is correct. I understand that I will not be individually denied coverage or be individually charged different rates as a result of my answers. However, if I knowingly provide false information on this Questionnaire, I understand and agree that it may affect the payment of claims or result in termination of my/or my dependent(s) coverage. EPLOYEE SIGNATURE / DATE 10SA0.03 CAT. #EW08873Rev 07/17
4 PROVISIONS Cigna Dental PPO plans are administered by CHLIC, with network management services provided by Cigna Dental Health, Inc. and certain of its subsidiaries. I agree, for myself and my covered dependents, that, in the event any health services provided are the primary responsibility of any other party by way of other group health coverage or by the act or omission of another person, I will fully inform the health plan and will execute such assignments, liens or other documents which may be necessary to enable the health plan to recover the value of the services provided. I further agree that in the event I or any of my covered dependents collect benefits or damages from any other party who has primary responsibility for services provided by the health plan, I will immediately reimburse the health plan to the extent permitted by state law. RAUD WARNING Any person who, knowingly and with intent to defraud any insurance company or other person: (1) files an application for insurance or statement of claim containing any materially false information; or (2) conceals for the purpose of misleading, information concerning any material fact thereto, commits a fraudulent insurance act. AUTHORIZATION TO DEDUCT CONTRIBUTIONS I authorize deductions from my earnings of the required contributions, if any, toward the cost of the coverage. This authorization applies only if employee contributions are required. SPECIAL PROVISIONS OR EPLOYERS WITH SECTION 125 PLANS By allowing an individual to enroll in the health plan, other than during the open enrollment period, Cigna Health and Life Insurance Company and its affiliates do not waive any terms of its contract. urther, by allowing an individual to enroll in the health plan, other than during an open enrollment period, Cigna Health and Life Insurance Company and its affiliates do not thereby express any opinion regarding the appropriateness of the change under Section 125 of the Internal Revenue Code or the terms of the employer s Section 125 Plan. All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company and Cigna Dental Health, Inc. and its subsidiaries. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc Cigna
5 DISCRIINATION IS AGAINST THE LAW edical coverage Cigna complies with applicable ederal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Cigna: Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages If you need these services, contact customer service at the toll-free number shown on your ID card, and ask a Customer Service Associate for assistance. If you believe that Cigna has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance by sending an to ACAGrievance@Cigna.com or by writing to the following address: Cigna ndiscrimination Complaint Coordinator PO Box Chattanooga, TN If you need assistance filing a written grievance, please call the number on the back of your ID card or send an to ACAGrievance@Cigna.com. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509, HHH Building Washington, DC , (TDD) Complaint forms are available at All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Cigna Behavioral Health, Inc., Cigna Health anagement, Inc., and HO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. ATTENTION: If you speak languages other than English, language assistance services, free of charge are available to you. or current Cigna customers, call the number on the back of your ID card. Otherwise, call (TTY: Dial 711). ATENCIÓN: Si usted habla un idioma que no sea inglés, tiene a su disposición servicios gratuitos de asistencia lingüística. Si es un cliente actual de Cigna, llame al número que figura en el reverso de su tarjeta de identificación. Si no lo es, llame al (los usuarios de TTY deben llamar al 711) a 05/ Cigna.
6
Prescription Drug Schedule Humana Medicare Employer Plan
PUB Name: GSB0012 2018 Prescription Drug Schedule Humana Medicare Employer Plan Rx 269 University of Richmond Y0040_GHHK48XEN18 (Pending CMS Approval) Rx 269 Let's talk about Humana Medicare Employer
2018 Individual Enrollment Request Form
2018 Individual Enrollment Request Form If you have questions, please contact AgeWell New York at: 1-866-586-8044 or TTY 1-800-662-1220 Fax Enrollment form to 1-855-895-0784 Please contact AgeWell New
GROUP SUBMISSION STATUS
q New Business Current Client or Group No(s) q Product Changes: Add Change* Renew As Is Cancel Medical q q q q Vision q q q q Dental q q q q *Include enrollment forms to report changes, if not signed up
SPECIAL ENROLLMENT PERIOD FORM
SPECIAL ENROLLMENT PERIOD FORM A Special Enrollment Period (SEP) is defined as a period during which you and your family have a right to sign up for new or make changes to existing health insurance coverage.
Check Plan Type: Check Enrollment Type: Fill Out Sections: q KP/HSA Small Group Employee Enrollment Form q Multi-Choice
Kaiser Foundation Health Plan of Georgia, Inc. Kaiser Permanente Insurance Company (KPIC) Check Plan Type: Check Enrollment Type: Fill Out Sections: q KP/HSA q New Hire A, B, C, D q Added Choice/HSA Added
Tufts Medicare Preferred Supplement. IMportant information. PO Box 9178 Watertown, MA 02472
Tufts Medicare Preferred Supplement 2018 Enrollment Application PO Box 9178 Watertown, MA 02472 IMportant information Please read the Important Information section, fill out the application on page 1,
2017 Medicare Blue PPO Group Health Plan Enrollment Request Form
2017 Medicare Blue PPO Group Health Plan Enrollment Request Form Return Applications to: Department of Human Resources Rochester Institute of Technology George Eastman Hall, 5th floor 8 Lomb Memorial Drive
Group Enrollment Application Change Form
Small Group Group Enrollment Application Change Form Please read the instructions on the inside thoroughly before completing this enrollment application/change form. Blue Cross and Blue Shield of Montana,
Employee Health Insurance Application
Small Business Employee Health Insurance Application A signature on page 4 is required to make the application valid. 1515 North Saint Joseph Avenue PO Box 8000 Marshfield, WI 54449-8000 1.800.472.2363
Group Enrollment Application Change Form
Group Enrollment Application Change Form Please read the instructions on the inside thoroughly before completing this enrollment application/change form. GHS Health Maintenance Organization, Inc. d/b/a
Division of Insurance
Division of Insurance COLORADO UNIOR EPLOYEE APPLICATION OR SALL GROUP HEALTH BENEIT PLANS This form is designed for an employee s initial application for coverage. Please contact your agent or the carrier
Any missing information may cause a delay in processing your request.
Member Reimbursement Claim Form *3000* This form may be used for Allwell Medicare products. Important: Complete a separate Member Reimbursement Claim Form for each member asking for reimbursement for covered
Enrollment Request Form
Employer name: Coverage effective date: Employer group number (Medical): Important Please print all sections in black ink. For the application to be valid, you must submit all applicable pages. 1. Select
Mail all medical claims to: or Mail all behavioral health claims to: Any missing information may cause a delay in processing your request.
Member Reimbursement Claim Form This form may be used for Health Net Medicare products. Important: Complete a separate Member Reimbursement Claim Form for each member asking for reimbursement for covered
Your Vision Website from Health Net
Your Vision Website from Health Net See it to believe it! Kim Aung Health Net Your Health Net of California, Inc. and Health Net Life Insurance Company (Health Net) vision member website offers detailed
Prescription Drug Claim Form
Prescription Drug Claim Form This claim form is to be used for reimbursement on covered medications provided by pharmacies. The filing of this form does not guarantee reimbursement. Please consult your
MEMBER CHANGE FORM P.O. Box Minneapolis, MN Customer Service (763)
CHANGE IN COVERAGE: Please use black or blue ink only. Do not highlight any areas on this form. Change subgroup from: to: Date: Change product from: to: Date: Change class from: to: Date: Change network
Name: Date of Birth: Gender: Telephone: Address: Check if you do not have a Health Care Proxy. Name: Relationship to Participant: Address:
Enrollment Agreement Name: Date of Birth: Gender: Telephone: Address: Health Care Proxy Check if you do not have a Health Care Proxy Name: Relationship to Participant: Address: Telephone: Guardian or Other
Coverage Through Employer/Union name Grp# Last Name: First Name: Middle Initial: 9 F
PO Box 9178 Watertown, MA 02472 2019 Employer Group HMO Election Form Please contact Tufts Health Plan Medicare Preferred if you need information in another language or format (Braille). DATE STAMP Please
Group Enrollment Application Change Form
Group Enrollment Application Change Form Please read the instructions on the inside thoroughly before completing this enrollment application/change form. Blue Cross and Blue Shield of Illinois, a Division
Sharp Advantage Employer Group Enrollment Form
2017-2018 Sharp Advantage Employer Group Enrollment Form To enroll in Sharp Advantage please provide the following information: Effective Date of Coverage: MM/DD/YY ( / 01 / ) Employer or Union Name: City
Group Enrollment Application Change Form
Group Enrollment Application Change Form Please read the instructions on the inside thoroughly before completing this enrollment application/change form. Blue Cross and Blue Shield of Texas, a Division
Employee Enrollment Form
Employee Enrollment orm (DO NOT STAPLE) To speed the enrollment process, please be thorough and fill out all sections that apply. Group To Be Name Completed by Employer Requested Effective Date of Coverage/Date
Enrollment application & change of information form
Enrollment application & change of information form Dental (2-4) Delta Dental use only Group number Subscriber number To expedite your application, please print legibly in black or blue ink and return
2019 SUMMARY OF BENEFITS
2019 SUMMARY OF BENEFITS Vitality Health Plan of California (HMO) County and County H1426 001/002/003 H1426_19_078_MK_ENG_M H1426 001/002/003 Vitality Health Plan of California January 1, 2019 December
APPLICATION FOR NEW 2018 INDIVIDUAL/FAMILY PLAN HEALTH INSURANCE
APPLICATION FOR NEW 2018 INDIVIDUAL/FAMILY PLAN HEALTH INSURANCE This Application is for coverage during the calendar year 2018. PLEASE COMPLETE STEPS 1 6. If you are an insurance agent/producer, please
Health Options Program Option Selection Period FAQs
Health Options Program Option Selection Period FAQs The Health Options Program Q What is a Qualifying Event? A A Qualifying Event is what makes you eligible for enrollment in the Health Options Program.
Membership Change Form
Membership Change Form Medicare Supplement Plans Maryland, District of Columbia and Virginia Residents Mailroom Administrator P.O. Box 14651, Lexington, KY 40512 Fax: 410-505-2901 or toll free 800-305-1351
Application Instructions
Application Instructions Thank you for your interest in Geisinger Gold. Please read carefully before completing each section of this enrollment application to help ensure quick processing of your new Geisinger
2019 Qualified Health Plan (QHP) transparency reporting for Individual HMO
2019 Qualified Health Plan (QHP) transparency reporting for Individual HMO Information on Explanation of Benefits (EOB) Your EOB is a statement that shows what health services you received, what bills
2017 Summary of Benefits
P.O. Box 52424, Phoenix, AZ 85072-2424 2017 Summary of Benefits Employer PDP sponsored by The Coca-Cola Company () A Medicare Prescription Drug Plan (PDP) offered by Insurance Company with a Medicare contract
Colorado Individual and Family Plan Supplemental Enrollment Form
Primary Applicant Name Enrollment orm ID Cigna Health and Life Insurance Company (Cigna) Colorado Individual and amily Plan Supplemental Enrollment orm This form must be completed alongside the Colorado
Summary Of Benefits January 1, December 31, 2019
Summary Of Benefits January 1, 2019 - December 31, 2019 Blue Shield of California Promise Health Plan is an independent licensee of the Blue Shield Association Care1st is an independent licensee of the
Individual Enrollment Form
Please contact Sunshine Health Medicare Advantage if you need information in another language or format (Braille). To enroll in Sunshine Health Medicare Advantage, please provide the following information:
2017 Summary of Benefits
P.O. Box 52424, Phoenix, AZ 85072-2424 2017 Summary of Benefits Employer PDP sponsored by Shell () A Medicare Prescription Drug Plan (PDP) offered by Insurance Company with a Medicare contract January
2019 Health Insurance Application
1515 North Saint Joseph Avenue PO Box 8000 Marshfield, WI 54449-8000 1.844.293.9624 715.221.9258 TTY: 711 Fax: 715.221.9500 Individual and Family 2019 Health Insurance Application FOR STAFF/AGENT/BROKER
Request for Redetermination of Medicare Prescription Drug Denial
Request for Redetermination of Medicare Prescription Drug Denial Because we, Allwell, denied your request for coverage of (or payment for) a prescription drug, you have the right to ask us for a redetermination
Please contact Sharp Health Plan if you need information in another language or format (Braille).
2019 Sharp Direct Advantage SM Basic (HMO) & Sharp Direct Advantage SM Premium (HMO) Enrollment Form Completing your enrollment is your first step to becoming a Sharp Direct Advantage Medicare member.
Summary of Benefits January 1, 2017 December 31, 2017
Pennsylvania Northeastern and West Virginia Pennsylvania BLUE RX PDP Summary of Benefits January 1, 2017 December 31, 2017 This booklet gives you a summary of what we cover and what you pay. It doesn t
2019 Enrollment Request Form
Page 1 of 5 2019 Enrollment Request Form Please contact the plan if you need this information in another language or format (Braille). 1. Plan information Plan Sponsor CS VEBA Group Number GPS Employer
New Subscriber Enrollment, BCN Primary Care Physician Selection or Change of Status Form
New Subscriber Enrollment, BCN Primary Care Physician Selection or Change of Status orm Please read the following information before completing the attached New Subscriber Enrollment, BCN-Primary Care
Employee Enrollment Form
Employee Enrollment orm To speed the enrollment process, please be thorough and fill out all sections that apply. (DO NOT STAPLE) Group Name/Number UnitedHealthCare Insurance Company UnitedHealthCare of
If you want health insurance:
If you want health insurance: Complete this Anthem application and turn it in to your business manager! If you want a health savings account (and free money!) ollow the directions on page 2. Employer contributions
Employee Enrollment Form
Employee Enrollment orm To speed the enrollment process, please be thorough and fill out all sections that apply. Group To Be Name Completed by Employer Requested Effective Date of Coverage/Date of Change
Open Access Managed Plus plan
Open Access Managed Plus plan www.texashealthaetna.com 7T.02.100.1-TX (6/17) 1 Visit any doctor, no referrals needed A health insurance plan designed to meet your needs Get to know your new Texas Health
Participating Pharmacy 9 Non-Participating Pharmacy 7,8
Rx Spectrum $10/25/40 - $20/50/80 with $0 Pharmacy Deductible Outpatient Prescription Drug Coverage (For groups of 101 and above) Highlight: $0 Calendar Year Pharmacy Deductible $10 Tier 1 / $25 Tier 2
RE: Your Massachusetts State & Federal Medical Loss Ratio Rebate Important Information
Group Name Address 1 Address 2 City State Zip August 2018 RE: Your Massachusetts State & Federal Medical Loss Ratio Rebate Important Information Group Name: Group Number: Dear
In keeping with its mission and core values, we are committed to providing health care for people regardless of their ability to pay.
Dear Patient and Family: In keeping with its mission and core values, we are committed to providing health care for people regardless of their ability to pay. Our Charity Care/Financial Assistance: Medical
Instructions. 3. If you have life coverage, complete the section entitled LIFE AND AD&D OPTIONS. Make sure to complete the Beneficiary information.
Instructions 1. Your employer will complete section A. 2. Complete sections B through N. 3. If you have life coverage, complete the section entitled LIE AND AD&D OPTIONS. ake sure to complete the Beneficiary
Travel Tips. Health Net. for Stanford Students and their enrolled dependents
Health Net Travel Tips for Stanford Students and their enrolled dependents Kim Aung Health Net Wherever you go, Health Net Life Insurance Company (Health Net) has you covered Healthy travel packing list
Individual Enrollment Form
Please contact Peach State Health Plan if you need information in another language or format (Braille). To enroll in Peach State Health Plan, please provide the following information: Please check which
Summary of Benefits. Tufts Medicare Preferred PDP PLANS Employer Group Tufts Medicare Preferred PDP3
Tufts Medicare Preferred PDP PLANS 2018 Summary of Benefits Employer Group Tufts Medicare Preferred PDP3 The benefit information provided is a summary of what we cover and that you pay. It does not list
2019 Enrollment Request Form
Page 1 of 5 2019 Enrollment Request Form Please contact the plan if you need this information in another language or format (Braille). 1. Plan information San: Labor Alliance Managed Trust Group Number:
ENROLLMENT INSTRUCTIONS
ENROLLMENT INSTRUCTIONS UnitedHealthcare Group Medicare Advantage (HMO) and (Regional PPO) are Medicare Advantage Plans. UnitedHealthcare RxSupplement TM is an Outpatient Prescription Drug Plan that works
These are the Optional Supplemental Benefits you can buy.
These are the Optional Supplemental Benefits you can buy. If you are enrolled in Allwell Medicare, you have the choice to customize and enhance your coverage with optional supplemental benefits. For an
Please check which plan you want to enroll in: If you live in Litchfield, Hartford, New Haven, New London, Tolland, or Windham Counties: Sex: 9 M ( )
PO Box 9178 Watertown, MA 02472 2019 CarePartners of Connecticut (HMo) INDIVIDUAL ENROLLMENT FORM Please contact CarePartners of Connecticut if you need information in another language or format (Braille).
Employee Enrollment Form
Employee Enrollment orm To speed the enrollment process, please be thorough and fill out all sections that apply. Group To Be Name Completed by Employer Requested Effective Date of Coverage/Date of Change
Enrollment and Change Form
For internal use only Eligibility verified: Group #: Effective date: Dependent plan: Stanford Student Dependent Health Insurance Plan Enrollment and Change Form Important Please print all sections in black
Alternate Phone Number: ( ) Address: Sex: 9 M ( ) 9 F. Permanent Residence Address (P.O. Box is not allowed): City: State: Zip Code:
PO Box 9178 Watertown, MA 02472 2018 TUFTS MEDICARE PREFERRED HMO INDIVIDUAL ENROLLMENT FORM Please contact Tufts Health Plan Medicare Preferred if you need information in another language or format (Braille).
Children s Mercy Financial Assistance Application (Page 1 of 5) (03/18)
(Page 1 of 5) Some key requirements to be eligible for financial assistance are: 1. You must be a resident in the state of Kansas or Missouri. 2. You have a household income (adjusted for family size)
9 HMO Basic Rx $23.00 per month 9 HMO Value Rx $54.00 per month 9 HMO Prime Rx $79.00 per month 9 HMO Prime Rx Plus $99.
PO Box 9178 Watertown, MA 02472 2019 TUFTS MEDICARE PREFERRED HMO INDIVIDUAL ENROLLMENT FORM Please contact Tufts Health Plan Medicare Preferred if you need information in another language or format (Braille).
INTRODUCTION TO SUMMARY OF BENEFITS
INTRODUCTION TO This booklet gives you a summary of what we cover and what you pay. It doesn't list every service that we cover or list every limitation or exclusion. To get a complete list of services
Individual Enrollment Form
Individual Enrollment Form 2019 Focus DC (HMO SNP) A Medicare Advantage Special Needs Plan Focused on Diabetes Care How to Fill Out This Form IMPORTANT Please read! This form has eight pages numbered Page
2017 Medicare Blue Choice (HMO) and (HMO-POS) Individual Enrollment Request Form
2017 Medicare Blue Choice (HMO) and (HMO-POS) Individual Enrollment Request Form Excellus BlueCross BlueShield contracts with the Federal Government and is an HMO plan with a Medicare contract. Enrollment
Aetna HealthFund health reimbursement arrangement (HRA) plan R (8/18) aetna.com
Aetna HealthFund health reimbursement arrangement (HRA) plan 32.02.301.1 R (8/18) aetna.com Here s a health plan that can make your money go further It s an Aetna HealthFund HRA.* And it comes with a fund
Questions and answers about the Fixed Benefits Plan
Questions and answers about the Fixed Benefits Plan The Fixed Benefits Plan is a fixed indemnity plan. How does a fixed indemnity plan work? Fixed indemnity plans have no copays, deductibles, or coinsurance.
MA BENEFIT COMPARISON PLAN OPTIONS FOR MA-SMGP-COMP-1216
MA BENEFIT COMPARISON PLAN OPTIONS FOR -MA-SMGP-COMP-1216 Massachusetts Small Group Plan Design Comparison uctible Medical// / HMO Copay Plans HMO Value Platinum - $0/$0 0/ $7000 5 5 CIF 0 $200 $40 $70
Medical Benefits Claim Instructions
Medical Benefits Claim Instructions Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person files an application for insurance or statement of claim
Enhanced Rx $10/30/50 - $20/60/100 with $0 Pharmacy Deductible. Blue Shield of California
An independent member of the Blue Shield Association Enhanced Rx $10/30/50 - $20/60/100 with $0 Pharmacy Deductible Outpatient Prescription Drug Coverage (For groups of 101 and above) THIS DRUG COVERAGE
Unimerica Insurance Company
CA Key Accounts Employee Enrollment orm To speed the enrollment process, please be thorough and fill out all sections that apply. (DO NOT STAPLE) Unimerica Insurance Company Group To Be Name Completed
PPHP-PA HMO SNP Individual Enrollment Request Form Please contact PPHP- PA if you need information in another language or format (Large Print).
www.pphealthplanpa.com 901 Elkridge Landing Rd., Ste. #100 Linthicum Heights, MD 21090 1-800-405-9681 TTY 711 PPHP-PA HMO SNP Individual Enrollment Request Form Please contact PPHP- PA if you need information
Tufts Health Plan Tufts Medicare Preferred HMO Prime For Working-Aged Employees
Check if Complete Tufts Health Plan Tufts Medicare Preferred HMO Prime For Working-Aged Employees To ensure that your applications are processed as quickly as possible, just follow this checklist Employer
2019 Short Enrollment Request
Page 1 of 7 Medicare Advantage HMO South Region 2019 Short Enrollment Request FOR OFFICE USE ONLY Member ID no. Effective date of coverage Election period individual is enrolling in: AEP SEP ICEP IEP OEPI
Health Net Medicare Advantage Plans 2019 Optional Benefit Individual Enrollment Form
Health Net Medicare Advantage Plans 2019 Optional Benefit Individual Enrollment Form Health Net offers optional benefits for an additional monthly plan premium. This form may be used only by our current
You can enroll by phone, mail or fax. Simply choose the way that is easiest for you and follow the Enrollment Request Form Checkpoints below.
How to Enroll You can enroll by phone, mail or fax. Simply choose the way that is easiest for you and follow the Enrollment Request Form Checkpoints below. By phone Contact us at toll-free 1-877-714-0178,
REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION This form may be sent to us by mail or fax:
REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION This form may be sent to us by mail or fax: Address: Medicare Part D Prior Authorization Department P.O. Box 419069 Rancho Cordova, CA 95741
Using your pharmacy benefit
Using your pharmacy benefit Your pharmacy benefit services OptumRx is your plan s pharmacy services manager and is committed to helping you find cost-effective ways to get your medication(s). Set up your
Blue Shield of California Life & Health Insurance Company Vision Disclosure Form
Blue Shield of California Life & Health Insurance Company Vision Disclosure Form This disclosure form is only a summary of your vision plan. The group policy which you can obtain from your employer should
2019 SHBP Benefts at a Glance
UnitedHealthcare SHBP Members State of Georgia 2019 SHBP Benefts at a Glance For more coverage details for each of these plans, please visit welcometouhc.com/shbp or call 888-364-6352. Medical Choice HMO
: Silver S04S, Network S Coverage Period: 01/01/ /31/2017
: Silver S04S, Network S Coverage Period: 01/01/2017-12/31/2017 Summary of Benefits & Coverage: What this Plan Covers & What it Costs Coverage for: Individual or Family Plan Type: PPO This is only a summary.
Employee Enrollment Application
Employee Enrollment Application Your Anthem enrollment application is inside. It is essential that you read it carefully and complete all necessary sections. If you are a new enrollee Applying for health,
www.pphealthplanpa.com 901 Elkridge Landing Rd., Ste. #100 Linthicum Heights, MD 21090 1-800-405-9681 TTY 711 Provider Partners Pennsylvania Advantage HMO SNP Enrollment Form Please contact Provider Partners
Member Appeal and Grievance Process
Standard Member Appeal and Grievance Process Carefully read the information in this packet and keep it for future reference. It has important information about how to appeal/grieve decisions Blue Cross
SilverScript Insurance Company 2019 Medicare Prescription Drug Plan Individual Enrollment Form
2019 SilverScript Section 1: Please Read This Important Information Typically, you may enroll in a Medicare Prescription Drug Plan only during the Annual Enrollment Period between October 15 and December
Mail your completed claim form(s) and original, Medicare Part D Drug Claim Form detailed pharmacy receipts to:
Prime Therapeutics Questions about completing this form? Call 401-227-2958 or 1-800-267-0439 TTY: 711 8 a.m. 8 p.m.* Mail your completed claim form(s) and original, Medicare Part D Drug Claim Form detailed
Group Health Insurance Application/Change Form
FOR INTERNAL USE ONLY HIOS ID#: EC: 78124NY1000201-00 SBY1 Group Health Insurance Application/Change Form Please print clearly and complete all sections that apply to you Additional instructions are included
Pharmacy Benefits Member Guide
Commercial Pharmacy Benefits Member Guide Optimizing your pharmacy benefits for a healthier you Carol Kim, Health Net We focus on getting you the health information you need, when you need it. Understanding
Highmark Blue Cross Blue Shield: my Priority Blue Flex HMO 1000G Coverage Period: 01/01/ /31/2017
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.highmarkbcbs.com or by calling 1-888-510-1084. Important
ENROLLMENT REQUEST FORM
ENROLLMENT REQUEST FORM Please contact Affinity Health Plan if you need information in another language or format (braille. To Enroll in Affinity Health Plan, Please Provide the Following Information:
Application for Medicare Supplement Insurance
Page 1 of 8 FOR STAFF/AGENT/BROKER USE ONLY 1515 North Saint Joseph Avenue PO Box 8000 Marshfield, WI 54449-8000 1.844.622.0805 715.221.9425 TTY 711 Amt. pd. Check no. Staff/Agent/Broker name Agent no.
Enrollment/Change Form
Enrollment/Change Form Thank you for choosing Empire. Please fill out all items in order for us to quickly and accurately process your enrollment. Once you ve completed this form, please sign in the space
Division: Subtotal Code:
THE GUARDIAN LIE INSURANCE COPANY O AERICA 7 Hanover Square, New York, NY 10004 Please print clearly and mark carefully. Page 1 of 5 Employer Name: Group Plan Number: Benefits Effective: PLEASE CHECK APPROPRIATE
Highmark Blue Cross Blue Shield: my Priority Blue Flex HMO 1700GQ Coverage Period: 01/01/ /31/2017
Coverage for: Individual/Family Plan Type: HMO This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.highmarkbcbs.com
Important Questions Answers Why this Matters:
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 1/1/2018 12/31/2018 Lifespan Health Coverage for: Individual/Family Plan Type: PPO The Summary
Cigna Health and Life Insurance Company Connecticut Individual and Family Plan Enrollment Application / Change Form
Primary Applicant Name Enrollment Form ID Cigna Health and Life Insurance Company Connecticut Individual and Family Plan Enrollment Application / Change Form Section A. Type of Application New Enrollment
Bronze 60 HDHP EnhancedCare PPO Plan Overview
California Individual & Family Plans Available through Covered California Health Net Life Insurance Company (Health Net) Bronze 60 HDHP EnhancedCare PPO Plan Overview Your Provider Network The Bronze 60
North Carolina Application for Dental Insurance
Section A. Dental Coverage Options: 1. Select who the coverage is for: Primary Applicant Only Primary Applicant and Dependent(s) Child(ren) Only 2. Select what coverage applicant(s) is/are applying for:
2014 Summary of Benefits. Empire Plan Medicare Rx sponsored by New York State Health Insurance Program (NYSHIP)
SilverScript Insurance Company Empire Plan Medicare Rx P.O. Box 52424, Phoenix, AZ 85072-2424 Empire Plan Medicare Rx sponsored by New York State Health Insurance Program (NYSHIP) 2014 Summary of Benefits
Coverage and a smart way to help pay for it Aetna HealthFund Health Savings Account (HSA) Plan
Quality health plans & benefits Healthier living Financial well-being Intelligent solutions Coverage and a smart way to help pay for it Aetna HealthFund Health Savings Account (HSA) Plan www.aetna.com
To Enroll in PPA, Please Provide the Following Information: Date of Birth (MM/DD/YYYY) Sex Home Phone Number q M q F
www.pphealthplan.com 901 Elkridge Landing Rd., Suite #100, Linthicum Heights, MD 21090 1-800-405-9681 TTY 711 Provider Partners Advantage HMO SNP Individual Enrollment Request Form Please contact PPA if