EFTA00521831.pdf

Employee Enrollment Form Pi UnitedHealthcare Virgin Islands To speed the enrollment process. please be thorough and fill out all sections that apply. m feted by Employer Requested Effective Dale of Coverage/Date of Chang, / / Group Name Policy Number Oat. of Hire Reason for Application Employee Type I New Group Plan • New Hire (Check all that apply) Pdadidnfrilla execullite a si,:tfan Life Event/Date Status Change Annual Open Active COBRA i State Continuation Stan dt _/_/ Hours Worked per week Dependent AddrDelete Enrollment End dt / / Change Name/Address Late n Hourly Salary Part time to Full time Enrollee a Union 7, Non-Union a Retied Salary $ Required only if Life. STD. Waiving Coverage Termination o Other or LID Plan based on salary Other A. Employee Information II you are waiving all coverage. please complete sections A and B. Last Name ShfI;a k Address /004__ed Noo4 Apt Lip Code Home/Cell Phone ociPet Date of Birth Gender I Marital Status f Single remarried O Divorced o Widowed Work Phone M "IF f Language Preference. if not English Emil Address Do you use tobacco?' n Yes II yes, are you currently participating in a tobacco cessation program or do you intend to pin one? D Yes O No Prima4 Care Physician' Existing Patient? }es u No Primary Care Dentist' Physician First & Larne/2c pTau Plosiermit'zi 2 Addrw/Yf Dentist First Last Name pr forrnachiaro / /"Iif te-io? 7:6 7e? ID/ tof kr, e,A, re' 3.3rat Existing Pa ent? nes r - No Declining coverage due to existence of other coverage. I understand that by waiving coverage at this time, I I decline all coverage for. Spouse's Employer's Plan Individual Plan mil not be allowed to participate unless I qua* at a Myself Covered by Medicare Medicaid special enrollment period or as a late enrollee. if 'Spouse COBRA from Pnor Employer VA Eligibility Tn-Care applicable. or at the next open enrollment period. Wependent Children Myself and all dependents I (we) have no other coverage at this lime Other Date Employee Signature if waiving all coverage fa! Coverage Provided by llndedHealthcare and Affiliates'. Medical coverage provided by UnitedHeafthcare Insurance Company Dental coverage provided by UnitedHeahcare Insurance Company Lde, Short-Term Disability (STD), Long-Term Disability (LTD) Insurance coverage provided by UntledHeatthcare Insurance Company • Vision coverage provided by UniledHeanhcare Insurance Company Pipe 1 el C15:051 Ills EFTA00521831  Employee Name C. Family Information List All Enrolling (Attach sheet II necessary) / 147 , F First Name MI Sex Date of Berth Last Name ri M F / Relationship' Spouse you currency participating /Domestic Social Security Number Do you use tobacco? r i Yes i INo II yes, are : ) Yes o No Partner 1 I 1-1 I I-I I I l in a tobacco cessation program or do you intend to pin one? Primary Care Dentist' Existing Patient? o Yes L: No Primary Care Physician' Existing Patient? E Yes 2 No Dentist First & Last Name Physician First .6 Last Name Address IDS IDS — Last Name First Name MI Sex Date of Birth Relationship' -: M F / / Social Security Number Do you use tobacco? Yes :: No II yes, are you currently participating Dependent in a tobacco cessation program or do you intend to pin one? [7: Yes E No i 1 1 1- I I I-I 1 I 1 Existing Patient? o Yes o No Primary Care Physician' Existing Patient? .- 1 Yes Li No Primary Care Dentist' Physician First & Last Name Dentist First & Last Name Address IDS IDS _ Permanently disabled and age 26 or older' 71Yes 0 No _ First Name MI Sex Date of Birth Relationship' \Last Name JPA F / / Dependent Social Security Number Do you use tobacco? v Yes n No If yes, are you currently participating in a tobacco cessation program or do you intend to join one? Yes No I I — I 1 1- 1 I I I . Primary Care Physician' Existing Patient? Yes No i Primary Care Dentist' Existing Patient? i.: Yes Ei No Physician First & Last Name Dentist First /3 Last Name Address ID* ID* Permanently disabled and age 26 or older' I: Yes No Last Name I First Name MI Sex Date of Birth Relationship' nMoF / / Social Security Number Do you use tobacco? ::Yes : - No tf yes, are you currently participating Dependent ii a tobacco cessation program or do you attend to join one? o Yes :.: No I I I- l-f I I Primary Care Physician' Existing Patient? -Yes No Primary Care Dentist' Existing Patient? o Yes o No Physician Firs 8 Last Name Dentist First & Last Name Address ID. ID. - Permanently di bled and age 26 or older' E Yes C No First Name MI Sex Date of Birth Relationship. Last Name M Li: F / / Social Security Number Do you use tobacco?' ' 'Yes No II yes. are you currently participating Dependent in a tobacco cessation program or do you intend to pin one? :: Yes 7] No 3 i I _I I— I I I Primary Care Physician' Existing Patient? 7) Yes il No Primary Care Dentist' Existing Patient? i: Yes 7: No Physician Firs 8 Last Name Dentist First & Last Name Address DP ID# - Permanently disabled and age 26 or older' :, Yes : :No Tobacco means all tobacco products. including, but not limited to, cigarettes cigars. and chewing tobacco. You6should only check the yes box above it tobacco was used four or more times per week on average (excluding religious or ceremonial use) within the past months by someone ol legal age to and other products requiring you to choose a purchase tobacco in the state ol residence. (2) For Unitedlieethcare Compass, Navigate, Select Select Plus. of your covered dependents. primary Care Physician (PCP), you must use the UnitedHealthcare directory al providers to choose a PCP for yourself and each (3) Please see employer representative as some dental plans require a Primary Care Dentist (PCD) selection. (4) For court ordered dependent. legal documentation must be attached. If a dependent does not reside with eligible employee. please provide address on a separate sheet (6) If you answered 'Yes* for Disabled and the dependent child is 26 years of age or older, unmarried. chiefly dependent upon subscnber for support and is not able to be self - supporting because of a physically or mentally disabing injury. illness or condition, please attach a medical cerulicabon of cksalaikty Pap 2 oi 4 EFTA00521832  Employee Name _ Please check the box for each coverage in which you or your dependents are enrolling. dollarA/ /A - amount ll your employer offers a choice of plans, indicate which plan you are selecting Indicate theShort -Term Disability D. Product Selection selected for the Life and Accidental Death & Dismemberment (A08.0). Supplemental lie. (STD). and Long-Tenn Disabihly (LTD) plans. Benefit offerings are dependent upon employer selection. Person Medical Dental Vision Basic Lite/AD&D Supp Lile/ADEID Employee u Spouse/Oomesnc Partner of Dependent o$ oj Person STD LTD Employee Life Insurance Beneficiary Full Name and Address PI applArg to lie Muraough UnlIvAleaMore) Relationship Primary Secondary E. Prior Medical Insurance Information W in the last 12 months. have you, your spouse, or your dependents had any other medical coverage? !t40 YES Of yes, please complete this section ) Prior medical carrier name Effective date End date Prior coverage type'. Employee Spouse Child(ren) Family F. Other Medical Coverage Information This section must be completed. (Attach sheet if necessary.) On the day this coverage begins. will you. your spouse a any of your dependents be covered under any other medical health plan or policy, including another UnitedHealthcare plan or Medicare? 0 YES (continue completing this section) 140 (skip the rest of this section) Other Group Medical Coverage Information Type Effective Date End Date Name and date of birth of policyholder (only list those covered by other plan) (B/S/F)' MNVDO/YY MNVDDAY for other coverage Employee: Spouse Name: Dependent Name: Dependent Name: Dependent Name: • &Enter '8' when this dependent is covered under both you and your spouse's insurance plan (married) S. Enter 'S' if you are the parent awarded custody o this dependent and no other individual is required to pay for this dependent's medical expenses F. Enter 'F if this dependent is covered by another individual (not a member of your household) required to pay for this dependent's medical expenses Medicare — Employee Information. If enrolled in Medicare, please attach a copy of your Medicare ID card. Enrolled in Part A: Effective Date Ineligible for Part A' Not Enrolled in Part A (chose not to enrolO• • Enrolled in Part B. Effective Date Ineligible for Part Not Enrolled in Part B (chose not to enroll)" Enrolled in Part D: Effective Date . Ineligible for Part EI• I: Not Enrolled in Part D (chose not to enroll)• • Reason for Medicare eligibility: Over 65 • Kidney Disease Disabled (2 Disabled but actively at work Are you receiving Social Security Disability Insurance (SSDI)? , . YES c: NO Start Date ___ Medicare — Spouse/Dependent Name. Enrolled in Part A Effective Date Ineligible for Part A' Not Enrolled in Part A (chose not to enroll)• • Enrolled in Part B. Effectrve Date • : Ineligible for Part r Not Enrolled in Part B (chose not to enroll)" Enrolled in Part D. Effective Date Ineligible for Part D' Not Enrolled in Part D (chose not to enroll)" Reason for Medicare eligibility. Over 65 Kidney Disease Disabled Disabled but actively at work 'Only check 'Ineligible' it you have received documentation from your Social Security benefits that indicate that you are not eligible for Medicare. • ' II you are eligible for Medicare on a primary basis (Medicare pays before benefits under the group policy). you should enroll in and maintain coverage under Medicare Part A, Part B, and/or Part D as applicable. Page 3 of 4 EFTA00521833  G. Signature Your enrollment in the plan is expressly conditioned upon your acceptance of all terms and conditions contained in this enrollment application. It you do not agree to the following terms and conditions, you may not complete your enrollment. TERMS AND CONDITIONS As a condition of my and/or my dependents' participation in the plan, and in consideration for the privileges that come from participation in the plan. I hereby agree for myself and/or for my dependents as follows. that all I recognize and understand that the plan contracts with physicians and other providers that make up the plan network. I recognize and pursuant physicians and other providers that participate in the plan network are subject to credentialing under applicable State regulations and to the plan's network credentialing process. I understand that such credentialing includes a review of provider education. training and I am licensure. However, by participating in the plan I hereby acknowledge and accept that the plan is not a provider of medical services. that the aware that obtaining or not obtaining medical care involves significant risks such as serious injury and even death. I acknowledge for, and credentialing of physicians and other providers does not in any way reduce this risk. I agree to assume all risks and responsibility hold the plan harmless from. any and all claims for damages. including personal injury or death, medical expenses. disability, lost wages, and loss of earning capacity which may be incurred or associated with medical treatment obtained through a participating physician or other provider. I recognize that all physicians and other providers that participate in the plan network are independent contractors and not the plan's medical treatment employees or agents and are solely responsible for any malpractice. adverse outcomes, or any other claims arising from dependents. I HEREBY AGREE THAT THE PLAN IS NOT RESPONSIBLE NOR LIABLE FOR ANY ADVICE. COURSE OF rendered to me and my A SERVICES OR PRODUCTS THAT I OR MY DEPENDENTS OBTAIN THROUGH TREATMENT, DIAGNOSIS OR ANY OTHER INFORMATION. PARTICIPATING NETWORK PHYSICIAN OR OTHER PROVIDER. suitability of I recognize and understand that the plan does not recommend. endorse or make any representation about the appropriateness or and any health and any specific tests, products, procedures. treatments. services. or opinions. I recognize that the plan, plan documents. diagnosis or wellness information provided by the plan, are not intended or implied to be a substitute for professional medical advice. medical information obtained from or through the plan with other sources. and will review all information treatment. I agree to confirm any MEDICAL ADVICE regarding any medical condition or treatment with my physician. I HEREBY AGREE TO NEVER DISREGARD PROFESSIONAL THE PLAN. OR DELAY SEEKING MEDICAL TREATMENT BECAUSE OF SOMETHING I HAVE READ OR ACCESSED THROUGH I authorize UnitedHealthcare Insurance Company and its affiliates (collectively, 'UnitedHealthca re') to obtain, use and disclose my medical, benefit records. including any individually identifiable health information contained in these records. I understand these records may claim or regarding the use of drug. contain information created by other persons or entities (including health care providers) as well as information psychotherapy notes). sexually transmitted disease and reproductive health services. I authorize alcohol, HIV/AIDS. mental hearth (other than or other medical facility, health care any health care provider, pharmacy benefit manager, other insurer or reinsurer. hospital. clinic to UnitedHealthcare and Affiliates. clearinghouse. and any of their affiliates. representatives or business associates, to disclose my information the appropriate purpose of the disclosure and use of my information is to allow UnitedHealthcar e to facilitate I understand that the benefits. I further understand that the information disclosed will not be used for purposes management of treatment, services. payment and is voluntary and I may refuse to sign the of eligibility. enrollment. underwriting and premium risk rating. I understand this authorization my UnitedHealthcare representative in wnting, except to authorization. I understand I may revoke this authorization at any time by notifying been taken in reliance on this authorization. As required by HIPAA. UnitedHealthcare also requires that I the extent that action has already understand that information I authorize a person or entity to obtain and use may be re-disclosed and acknowledge the following, which I do. I authorization, unless revoked earlier, expires 30 months after the date it is signed. no longer protected by federal privacy regulations. This response must be complete and accurate. I (we) request the f understand that I am completing a joint fife and health application and that each required premium contributions to be deducted from my earnings. I (we) have not given the indicated group medical coverage. I authorize any or any other persons any required information not included on the application. I (vie) understand that UnitedHealthcare is not bound by agent have made to any agent or to any other persons, if those statements are not written or printed on this application and any statements I (we) any attachments. form we may be allowed by law to take one or more of the Please note that if you leave out information or make a misrepresentation on this your coverage or change your premium retroactively to the date your policy became effective. following actions. terminate or non-renew Please maintain a copy of this authorization for your records. Date • y go Employee r all applying Ouse Signature (if applying for coverage) i07/140/f H. Census Information (optional) section will be used only to help communicate with NOTE: Responding to this question is optional and is not required. Data collected in this them of specific programs to enhance their well-being. This information will not be used in the eligibility process. enrollees and inform L White Black. African-American American Indianthlaska Native ri Asian 1. Race. check all that apply: Y. Native Hawaiia&Pacitic Islander Other Race, please specify 2. Are you of Hispanic or Latino origin? a Yes ❑ No Par 4 of 4 EFTA00521834