EFTA00558269.pdf

New York Member Enrollment Form - OHI UnitedHealthcare MAILING ADDRESS: P. 0. Box 7085, Bridgeport CT 06601 • 1-800-444-6222 • www.oxfordhealth.com Oxford A. Group Information (To be completed by the employer) Please print neatly using black or blue ballpoint pen • ALL DATES MUST BE: MM/DD/YYYY Group Number Group Name Ran CSP Billing Group Date of Hire Effective Date Occupation / / / / rl On Leave of Absence O Retired COBRA/Young Adult/SC Qualifying Event Date Em er Signature I. a Date O Union Employee CJ Disabled Event / / X 0/ / /8 /a70/3 B. App/Mont Details (To be completed by the employee) Employee/Subscriber Spouse Grill Child Sods) Security Number: Last Name: First Name, Weddle Initial: Date of Birth: . (MM/DDNYYY) _ / / / / 1 Gender and Disabaty Status: (Check appropriate boxes.) Oki OF I El Disabled DM OF / OD shied OM OF / °Disabled OM OF / °Disabled Primary Care Physician (PCP) ID Number: PCP Name: (If an skiing patsy of PCP, check Wee.) E Yes C Yes O Yes O Yes . Check all that apply: O Domestic Partner O RI-time Student • O Full-time Student .-- O Young Adult :O Young Adult Prior Carrier Cartier. II hi I kg )--IPL/4/14/ (List coverage prior to this.) Policy Number: From Date / I I / 1 I / 1 IftiSsme for el Thu deb:: C. Coordination of Benefits Employee/Subscriber Spouse Child . . Child Check appropriate 1:. Pan A / O Part A / / O Part A / / O Part A / / Medicare Coverage box and list i 7 Pan B I n Part B / / O Part B / I .O Part B / / effective date: L] Pan D / O Part D / / CI Pert D / / O Part D / / Pharmacy Pokey Number: O Same for al Cartier: Policy udder: Effective Date: Group Number: DIN SIN: BIN: / / RCN: PCN: PCN: Poky Number: Medical Carrier. II Same for all Policy Holder: Effective Date: / / / I / I I ea! Pines.. ml emit n • rasa me um kMIld • k bfal tea. sera Walt I anal Pc • Pt ti wk wens lot Inv. oda nsket of fri u P.* M Itfof G,I Pett krill. • My nOISPAOlsaibigolos al• tha•Inkil twit Om at gbe linnt Here ~mart, PANS.. bee sweat I .4 x.101. Po • eullaflu• Peru..•7w. • Wad.. •• an • ms.,nra own alma Me • we • mos • ismild dui •• no* is Sipa • *eels de mow 0 NINON ••••••oste *,M •PI4 PSl oteesilamparasce a POI • uN Sisainiact in pith t.nWi w .• ase ea ft as I. en so was aas ft ** INNS • raw *PS ! emti• • n aoliseN tivlaN.b.darkesissind Employee's/Young Adult's Address (Apt //) Employee's/Young Adult's Signature Dale State Zip / / ! QV X OHINY MEP L$1109 4919 REV it EFTA00558269