Supplemental Information Form For Employees (Page 2 of 2) in pdf

eMPLOYeeS ReTIReMeNT SYSTeM OF TeXAS

Texas Employees group Benefits Program (gBP) Supplemental Information form for Employees

GeNeRAL INSTRUCTIONS

This GBP Supplemental Information Form is NOT an enrollment form. Enrollment forms are submitted to ERS and coverage is reported to the selected

health plan. This form will facilitate the receipt of your health care identification card once your enrollment form has successfully been processed by ERS

and your coverage reported to the selected health plan.

This GBP Supplemental Information Form must be completed, signed and dated by you when:

1) enrolling in any GBP health plan, 2) adding a dependent to your current health coverage, or 3) making an eligible health plan change (for example, at

Annual Enrollment).

SeCTION A: eMPLOYee DATA

Complete this section and specify your mailing address, ZIP Code, and Eligibility County.

SeCTION B: OTHeR INSURANCe DATA

Complete this section if you or any member of your family are covered by other health or dental coverage. If more space is needed, please attach a

separate sheet.

SeCTION C: MeDICARe COVeRAGe INFORMATION

Complete this section if you or any member of your family are covered under Medicare Part A and/or Part B. If more space is needed, please attach a

separate sheet.

SeCTION D: PRIMARY CARe PHYSICIAN SeLeCTION

Complete this section if you are enrolling in a GBP health care plan requiring a primary care physician selection prior to receiving services. Refer to your

HealthSelect or Health Maintenance Organization (HMO) provider directories at when completing this section.

1. Write the name of your chosen health plan.

2. Write the name and provider code of your chosen primary care physician (PCP) for yourself and each covered dependent,

even if you are selecting the same physician for all covered persons.

3. Indicate if you are an existing patient or not (Y/N).

If you need assistance in completing this section, contact your health plan.

SeCTION e: OTHeR DePeNDeNT INFORMATION

1. Complete this section if you are enrolling in HealthSelect (In-Area) and your eligible dependent lives out-of-area or in

another HealthSelect network area.

2. Complete this section if you are enrolling in an HMO and your eligible dependent lives in another Texas service area of the

selected HMO.

SIgn, daTE, and maIl ThIS foRm To youR hEalTh Plan.