CERTIFIED STAFF Employee/Dependent Enrollment Application and Waiver of Coverage

Transcription

1 CERTIIED STA Employee/Dependent Enrollment Application and Waiver of Coverage PO Box 7068, Springfield, OR Phone: (541) or (866) ax: (541) SECTION 1: EMPLOYEE CONTACT INORMATION Employer/Group Name: Last Name irst Name Group Policy No: M.I. G Mailing Address City State Zip Address Phone Number Marital Status: arried Single Qualified Domestic Partner (registered or affidavit) SECTION 2: PLAN SELECTION MEDICAL: $300 Deductible/Co-Pay Plan $600 Deductible/Co-Pay Plan $2,000 Deductible/Co-Pay Plan (PT only) $1,500 Deductible H.S.A. DENTAL & VISION: PacificSource Dental & Vision Willamette Dental Group & PacificSource Vision Active Retiree Opt-Out/Decline Coverage Opt-Out/Decline Coverage SECTION 3: ENROLLMENT INORMATION BENEIT STATUS RELATIONSHIP LAST NAME IRST NAME MI GENDER SELECTION SEL SPOUSE/DOMESTIC PARTNER BIRTHDATE (m/d/y) SSN RACE/ ETHNICITY* *Race/Ethnicity (choose the code each member most closely identifies with): AIAN-American Indian/Alaska Native, A-Asian, B-Black/African American, H-Hispanic/Latino, N-Native Hawaiian/Other Pacific Islander, W-White/Caucasian

2 Do you have listed a dependent child over the age of 26 years? Yes No If yes, is the dependent developmentally/physically disabled? Yes No Are you or any listed dependents covered under Medicare? Yes No If yes: Name of covered: Part A Part B Part D Child Custody: If you or your spouse are a Court Ordered Guardian or are required to provide coverage for a child from a previous relationship, then you must complete this section in addition to the above and provide a copy of the legal documentation that shows responsibility for medical expenses. Please use additional paper if needed. NAME O CHILD LEGAL CUSTODY CUSTODIAL PARENT NAME MAILING ADDRESS WHO IS REQUIRED TO PROVIDE INSURANCE? other ather Joint Other SECTION 4: OTHER/PRIOR COVERAGE Were you or any listed dependents covered under another DENTAL plan within the last 24 months? Yes, complete below No Names: Are you or any listed dependents currently covered under another plan? Yes, complete below No Names: Dental Vision Names: Dental Vision Notice of enrollment rights: If you are declining enrollment for you or your dependents (including your spouse) because of other health insurance coverage, you may in the future be able to enroll yourself or your dependents in this plan, provided that you request enrollment within 60 days after your other coverage ends. In addition, if you have a new dependent as a result of a marriage, birth, adoption or placement for adoption, you may be able to enroll yourself and your dependents, provided that you request enrollment within 60 days after the marriage, birth, adoption or placement for adoption. In addition, you understand that by declining coverage, you and/or your eligible dependents must wait until my employer s next open enrollment period to enroll unless you and/or my eligible dependents qualify for a special enrollment period.

3 SECTION 5: ELECTRONIC COMMUNICATIONS AGREEMENT By checking the Yes box below, you affirmatively consent to the following: (1) to submit your application for enrollment on a PacificSource group policy filed electronically over a secured internet connection, (2) your electronic submission has the same force and effect as if you had submitted a paper application to PacificSource with your signature, (3) to receive secured electronic communications from PacificSource regarding your application and/or enrollment status, changes in insurance coverage, and termination of coverage, and (4) to keep PacificSource informed of your current address so we may continue to correspond with you. Your consent continues while the plan you enroll in is effective. You may, at any time, opt out of electronic communications. You may request a free paper copy of your application and/or enrollment information by contacting our Commercial Enrollment and Billing Department via at membership@pacificsource.com, or by phone at (866) Electronic communications are offered as a convenience only. Your decision to not receive electronic communications will not affect your enrollment. There is no charge associated with switching to paper. PacificSource highly recommends you keep a copy of your application and any associated materials. In order to complete the application electronically, you must have a personal computer or other device capable of accessing the internet and the ability to view and revise Portable Document ormat (PD) files. PacificSource may also send PD documents to you as part of the application process. You can obtain a free copy of software to view PD files at PacificSource takes the security of electronic information and communications seriously. If you have any questions about our encryption, technical hardware or software, or our security policies and procedures, please contact us at membership@pacificsource.com. I agree: Yes No SECTION 6: ACKNOWLEDGEMENT AND DECLARATION Subscriber acknowledgement: I acknowledge and understand that PacificSource Health Plans may request or disclose health information about me or my dependents (persons listed for benefit coverage on this enrollment form) for the purpose of facilitating healthcare treatment, payment for healthcare services, or for business operations necessary to administer healthcare benefits; or as required by law. This acknowledgement does not apply to obtaining information regarding psychotherapy notes. A separate authorization will be used for this information. or more information about such uses and disclosures please refer to our Privacy Policy that is available at PacificSource.com. Accuracy of enrollment information: I affirm that the answers given in this application are complete, true and correct to the best of my knowledge. I agree to promptly inform PacificSource Health Plans in writing if anything happens before my coverage takes effect that makes any answer on this application inaccurate or incomplete. Any person who, with an intent to knowingly defraud, files this application with materially false information or conceals material information, may be subject to criminal and civil penalties and PacificSource Health Plans may cancel such person s membership and refuse to pay their claims. Employee Signature: Date: Certified Active Retiree PSN $300 CoPay PSN $600 CoPay PSN $1500 H.S.A PSN $2000 CoPay Self-Insured Dental Willamette Dental OR OICE USE ONLY Effective Date of Change: Pay Type: PT / T Hours per week: Original Date of Hire: Employee Rep: Date: New Group Open Enrollment New Hire Adding Dependent(s) Involuntary loss of other group Date of Qualifying Event: TYPE O CHANGE Terminate Coverage for: Subscriber Spouse Child(ren) Eligible for Continuation Reason for termination:

4 Health Savings Account Authorization Agreement for Automatic Deposit Employee Information: Employee Last Name, irst Name, Middle Initial Employee Mailing Address (street) (City) (State) (Zip) How you are enrolled for your Medical Plan: single or 2-party + medical only or complete package? Bank Information - HEALTH SAVINGS ACCOUNT Bank Name Savings OR Checking (circle one) Banking Routing #: Account #: I authorize, hereinafter called Company, to initiate credit entries and to initiate, if necessary, debit entries and adjustments for any credit entries in error to my designated account, indicated above, and the depository named above, hereafter called Depository, to credit and/or debit the same to such account. This authority is to remain in full force and effect until eligibility ends or a new authorization agreement is submitted. Signature: Date: Account must be established and form returned to Payroll/Benefit office by open enrollment deadline or as soon as eligible for group insurance. **COMPLETE THIS PORTION ONLY I YOU WOULD LIKE TO MAKE AN ADDITIONAL CONTRIBUTION TO YOUR H.S.A. ACCOUNT** Voluntary Deduction Agreement Health Savings Account (choose one) Maximum Contribution Limit: Employee only or 2-party + Monthly Amount: By signing this form I agree to have the specified employee deductions remain in effect until eligibility or a new authorization agreement is submitted. I also understand I may not change or vary the amount within the Plan Year. I understand that it is my responsibility to ensure that contributions (employer + employee) do not exceed the IRS annual maximum contribution limit for an account owner with single coverage of $3,350 or family coverage $6,750 for 2016 calendar year or $3,400 single and $6,750 family rates for Individuals age 55 and older may contribute an additional $1,000 per calendar year. I have full responsibility to manage my H.S.A. account in accordance with IRS rules and regulations. I understand the voluntary deduction for my Health Savings Account will be reduced from my compensation on a PRE-TAX basis. Signature: Date: Account must be established and form returned to Payroll/Benefit office by open enrollment deadline or as soon as eligible for group insurance. Completed by Payroll /Benefit Office: Max contribution: District Contribution:

5 Beneficiary Designation orm or residents of Oregon and Washington, the definition of a Spouse includes your legal husband or wife or your State Certified/Registered Domestic Partner. Please contact your employer for any additional eligibility requirements. or residents of Idaho, Utah, Montana and Wyoming, the definition of a Spouse includes your legal husband or wife. Please contact your employer for any additional eligibility requirements. Please print in blue or black ink; complete all information requested. Employer Name New Designation If you wish to name additional beneficiaries, please attach a separate piece of paper with all of the necessary information, including the date and your signature. Primary Beneficiary (Last, irst MI) Date of Birth M Change of Existing Designation Employee s Name (Last, irst MI) Date of Birth M LifeMap Assurance Company TM P.O. Box 1271, MS E-3A Portland, OR (503) (800) Group Number WBT00085 Primary Beneficiary (Last, irst MI) Date of Birth M If Primary Beneficiary(ies) dies before you, the benefit will be paid to your Contingent Beneficiary(ies). Contingent Beneficiary (Last, irst MI) Date of Birth M Sign, date and return this form to your Benefits Administrator. Signature of Employee Date Signed Instructions for Completing Your Beneficiary Designation The Primary Beneficiary receives the Life and AD&D proceeds upon your death. You may have more than one Primary Beneficiary. If so, please provide all requested information, and the percentage of proceeds you would like each Primary Beneficiary to receive. The Contingent Beneficiary receives proceeds only if the Primary Beneficiary(ies) dies before you. Please provide all requested information. Examples follow: A. One Primary Beneficiary Mary R. Jones 100% (list information) B. Two or more Primary Beneficiaries 50% to John Jones and 50% to Sally Smith (list info. for both) C. Two or more Primary Beneficiaries in Unequal Shares 75% to John Jones and 25% to Sally Smith (list info. for both) D. One Primary and Contingent Beneficiary 100% to Mary R. Jones, if living, otherwise to Sally Smith (list info. for both) E. Trustee Mary R. Jones, Trustee, under trust agreement dated. Insured s Estate My Estate Under items B. and C. above, if one of the Primary Beneficiaries dies before you, 100% of the proceeds will go to the living Primary Beneficiary(ies). Do you know that if death occurs and a minor (a person not of legal age) is the beneficiary, it may be necessary to have a Guardian of the Estate of the minor, or a Conservator for the minor appointed before any death benefit can be paid? This means legal expenses for the beneficiary and delay in the payment of the insurance. Please take this into consideration when naming your beneficiary.