Enrollment Form. California. Instructions. Terms and Conditions Please read carefully before signing. Employee Signature
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1 California Enrollment Form Instructions Section 1: Personal Information Please complete information requested. Section 2: Selected Coverage Select only one of the plans offered by your Employer for you and your family. All family members must be enrolled in the same plan. Select the individual(s) to be covered under the plan you have selected. Section 3: Employee & Dependent Information List yourself and family members to be covered. You may attach additional sheets if necessary. Social Security Number is a required field for you and each of your family members. Select a Primary Care Physician (PCP) from the Provider Directory for you and each of your family members by writing the PCP name and Provider number in the area provided. You may choose a different PCP for each member in your family within your selected plan. PCP selection is only required if a UnitedHealthcare of California SignatureValue TM (HMO), UnitedHealthcare SignatureValue TM Advantage (HMO Value), UnitedHealthcare SignatureValue TM Flex (HMO), or SignatureValue TM Alliance (HMO) plan is selected. If you do not select a PCP when selecting one of these plans, a PCP will be automatically assigned to you. Verify that domestic partner coverage is available through your Employer. Unmarried enrolled Dependents require proof of dependency and incapacity status within 60 days of receipt of notice and prior to the Dependent reaching the Limiting Age. Section 4: Benefit Coordination/Other Insurance Carrier Information Please complete information requested, if applicable. Employee Signature You can either: Accept the health care services coverage provided through your Employer by signing the space provided on the enrollment form. Your signature indicates that you have read, understand and agree to the terms and conditions below. Affixing your signature also indicates your acceptance of payroll deductions (if necessary) to pay your share of the cost. OR You can waive the health care services coverage provided through your Employer for yourself, your spouse, domestic partner or your Dependents by signing the DECLINATION OF COVERAGE FORM. We strongly recommend that you read through the entire form carefully before signing your name in ink and dating it. Please request the Declination of Coverage Form from your Employer. Terms and Conditions Please read carefully before signing On behalf of myself and my eligible Dependents, I hereby apply for health care services coverage indicated in UnitedHealthcare s Group Health Plan offered through my Employer, and agree to and understand the following: 1. To be bound by the UnitedHealthcare Medical and Hospital Group Subscriber Agreement ( Agreement ) if I have chosen the UnitedHealthcare SignatureValue TM (HMO), UnitedHealthcare SignatureValue TM Advantage (HMO Value), UnitedHealthcare SignatureValue TM Advantage - Plan Bien SM (HMO), UnitedHealthcare SignatureValue TM Flex (HMO), or UnitedHealthcare SignatureValue TM Alliance. 2. My Employer may deduct from my earnings the employee contribution required to cover my share of the premium, if any. 3. UnitedHealthcare or a designee may access and/or use my medical records and the medical records of my enrolled Dependents, including mental health medical records and medical records from substance use disorder treatment or prevention, for purposes of Utilization Review, Quality Assurance, Surveys, Processing of Claims, Financial Audit or other purposes reasonably related to the performance of treatment, payment, or health care operations of the Agreement.
2 4. Any intentional misrepresentation of a material fact in answering the questions on this application may result in the denial of benefits and the termination of my and/or my Dependents membership with UnitedHealthcare. 5. Coverage shall not begin until acceptance of this enrollment by UnitedHealthcare. Upon acceptance of this application, UnitedHealthcare shall be bound by the terms of the Agreement, and any Amendments thereto. 6. I have received, read and understand the UnitedHealthcare Combined Evidence of Coverage and Disclosure Form, Directory of Participating Medical Groups and a copy of this Enrollment Form. 7. My Dependents and I must reside in California, live or work in UnitedHealthcare of California s service area. 8. If my Dependents or I elect UnitedHealthcare SignatureValue TM (HMO), UnitedHealthcare SignatureValue TM Advantage (HMO Value), UnitedHealthcare SignatureValue TM Flex (HMO) or UnitedHealthcare SignatureValue TM Alliance, we will select a Primary Care Physician within a 30-mile radius of our Primary Residence or Primary Workplace. UnitedHealthcare SignatureValue TM (HMO), UnitedHealthcare SignatureValue TM Advantage (HMO Value Network), UnitedHealthcare SignatureValue TM Flex (HMO), and UnitedHealthcare SignatureValue TM Alliance (HMO) P.O. Box Salt Lake City, UT (TTY) (Fax) Visit our Coverage provided by UnitedHealthcare and Affiliates. Medical coverage provided by UnitedHealthcare of California. Administrative services provided by United HealthCare Services, Inc., OptumRx or OptumHealth Care Solutions, Inc. Behavioral health products are provided by U.S. Behavioral Health Plan, California (USBHPC) or United Behavioral Health (UBH).
3 Employee Enrollment Form (Please Print) 1. Personal Information (Please print on all sections of form) California Employer Required to Complete This Section Company Name Date of Hire Group #/Plan Code Last Name First Name M.I. Suffix Residence Mailing Address City State ZIP Source of Enrollment: Open Enrollment New Hire Rehire Requested Effective Date QMCSO Employee Status Change Home Telephone Work Telephone Date of Birth (mm-dd-yy) Employer Verification/Signature Social Security # Marital Status Married Widow Single Divorced Domestic Partner Are you currently on COBRA? If yes, qualifying event: Preferred Language (optional) English Spanish COBRA Qualifying Event Effective Date Employee Class Ethnicity (optional) Black or African American Hispanic or Latino Caucasian Asian, Native Hawaiian, other Pacific Islander Not provided by member American Indian or Alaskan Native 2. Selected Coverage (Select only one of the plans offered by your Employer) Medical Plan Options: UnitedHealthcare SignatureValue TM (HMO) High Low UnitedHealthcare SignatureValue TM Advantage (HMO) UnitedHealthcare SignatureValue TM Advantage PlanBien SM (HMO) UnitedHealthcare SignatureValue TM Alliance (HMO) UnitedHealthcare SignatureValue TM Flex (HMO) Network 1 UnitedHealthcare SignatureValue TM Flex (HMO) Network 2 UnitedHealthcare SignatureValue TM Flex (HMO) Network 3 Individual(s) to be covered: Self Self + Spouse Self + Dependent(s) Self + Family Waive Medical (Complete Waiver Form) 3. Employee and Dependent Information (List yourself and family members to be covered attach additional sheets if necessary) Self Spouse/ Domestic Partner* Last Name First Name M.I. Date of Birth (mm-dd-yy) Social Security # Address, if different from Employee s Dependent 1 Dependent 2 Dependent 3 Dependent 4
4 California 4. Benefit Coordination/Other Insurance Carrier Information Does anyone listed have other health insurance? If yes, complete section boxes a e a. Name b. Insurance Company Name c. Policy # d. Effective Date e. Other Employer Name and Address Is anyone listed eligible for Medicare? If yes, complete section boxes f g f. Name g. Medicare ID# 5. Signature Required on Terms and Conditions Read Carefully By signing below, I acknowledge that I have read, understand and agree to the Terms and Conditions on all the pages of this form. A reproduction of this authorization shall be as valid as the original. I desire to participate in the coverages selected above and hereby authorize my Employer to make the necessary deduction(s) from my wage/salary to pay my portion of the premium. Signature (Required) X Date (Required) 6. Signature Required on Binding Arbitration Read Carefully By signing below, I acknowledge that I have read, understand and agree to the Binding Arbitration. A reproduction of this authorization shall be as valid as the original. I agree and understand that any and all disputes, including claims relating to the delivery of services under the plan and claims of medical malpractice (that is, as to whether any medical services rendered under the health plan were unnecessary or unauthorized or were improperly, negligently or incompetently rendered), except for claims subject to ERISA, between myself AND my DEPENDENTS enrolled in the plan (including any heirs or assigns) and UNITEDHEALTHCARE of CALIFORNIA, UNITEDHEALTHCARE or any of its parents, subsidiaries or affiliates shall be determined by submission to binding arbitration. Any such dispute will not be resolved by a lawsuit or resort to court process, except as the federal arbitration act provides for judicial review of arbitration proceedings. ALL parties to this agreement are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of binding arbitration. Signature (Required) X Date (Required)
5 Please open to complete this form
6 2012 United HealthCare Services, Inc. PCA
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All Active Plan A, B, Flat Rate and R Participants and their Dependents, including COBRA Beneficiaries
June 20, 2011 CARPENTER FUNDS ADMINISTRATIVE OFFICE OF NORTHERN CALIFORNIA, INC. 265 Hegenberger Road, Suite 100 P.O. Box 2280 Oakland, California 94621-0180 Tel. (510) 633-0333 (888) 547-2054 Fax (510)
Small Business Application
Small Business Application for Group Enrollment and Change Medical and Life/AD&D plans are provided by Health Net of California, Inc. and/or Health Net Life Insurance Company (together, Health Net ). Dental
3. Employee personal information Last name: First name: MI: Male Female
Employer name: Effective date: Employer group number (medical): (For enrollment, sections 1, 3 and 9 are required. For waivers, only section 8 is required.) Important: Please print all sections in black
Printed Name EID # Peralta Community College District Benefits Enrollment Checklist (Special Note to Part Time and Hourly faculty: Include documentation of all full time equivalent (FTE) for Academic Term)
Please complete in blue or black ink only. Section A: Employee Information Last name First name M.I. Social Security no.
Employee Enrollment Application For 2 50 Employee Small s Georgia You, the employee, must complete this application. You are solely responsible for its accuracy and completeness. To avoid the possibility
Welcome to Compass Medical!
ELECTRONIC FORM DISCLAIMER: Compass Medical is deeply committed to protecting our patient's rights to privacy and safeguarding patient information. Please know we are working hard to bring our patients
PATIENT INFORMATION Patient First Name Middle Name Last Name Age Birth Date. Mailing Address City State Zip. Street Address City State Zip
PATIENT INFORMATION Patient First Name Middle Name Last Name Age Birth Date Mailing Address City State Zip Street Address City State Zip Home Phone Cell Phone Employer Name (for work comp only) Employer
Employer Enrollment Application For Employee Small Groups California
Employer Enrollment Application For 1-100 Employee Small Groups California Health care plans offered by Anthem Blue Cross (Anthem). Insurance plans offered by Anthem Blue Cross Life and Health Insurance
MEMBERSHIP APPLICATION & CHANGE FORM WELCOME TO CIGNA HEALTHCARE!
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22259 SMALL GROUP ENROLLMENT/CHANGE FORM COMPLETE THIS APPLICATION IN ITS ENTIRETY IN BLUE OR BLACK INK. DO NOT USE PENCIL OR HIGHLIGHTER. q ENROLLING (Complete sections I, II, IV, and V) q WAIVING (Complete
Please fill out in blue or black ink only. Section A: Employee Information Last name First name M.I. Social Security no.
Employee Enrollment Form For 1-50 Employee Small s 1 New Hampshire You, the employee, must fill out this enrollment form. You must be sure that all the information is correct and that you fill out all