Health Care Eligibility And Enrollment Form - 2017 printable pdf download

UnitedHealthcare

9200 Worthington Road

Westerville, OH 43082

Phone: (888) 832-0964

Fax: (866) 459-0518

2017 HEALTH CARE ELIGIBILITY AND ENROLLMENT FORM

If you or your qualified dependents are non-Medicare eligible, early Medicare, Medicare A only, Medicare B only, or residing outside

of the U.S. complete and return this form to UnitedHealthcare Insurance Company (UnitedHealthcare) to enroll, re-enroll, or waive

yourself and your qualified dependents in the OP&F-sponsored health care plan if you are a new benefit recipient or if you have met

a qualification for re-enrollment.

If you or your qualified dependents are age 65 and over, Medicare eligible and enrolled in Medicare Parts A and B, you will be

eligible to enroll in an OP&F-sponsored AARP Medicare Supplement Insurance Plan, insured by UnitedHealthcare Insurance Company

(UnitedHealthcare Insurance Company of New York for New York residents). Please call (800) 392-7537 for additional information.

You will, however, be required to complete and return this form to UnitedHealthcare to enroll, re-enroll or waive yourself or your

qualified dependents in the OP&F-sponsored health care and/or prescription drug coverage if you are a new benefit recipient or if

you have met a qualification for re-enrollment.

UnitedHealthcare must receive this form within 60 days of the qualifying eligibility event or within 60 days of receiving your interim

benefit payment in order for your request to be valid. If this form is not received within 60 days of the qualifying event, your

request for enrollment will be denied and you will have very limited opportunities to re-enroll. Please refer to the Members’ Guide

to Health Care Coverage for 2017 for detailed eligibility guidelines and re-enrollment opportunities.

I am, or will soon retire and become a new benefit recipient.

I have met a qualification for re-enrollment in the OP&F-sponsored health care plan below.

Three years after OP&F retirement or commencement of benefits

Change in family status - Please provide proof of the change (ie. adoption papers, marriage certificate, divorce decree)

Involuntary loss of group coverage - Please provide proof of loss including the termination date of the coverage and

all dependents covered. (i.e., Medicaid, COBRA, employer coverage)

Medica

re eligibility - Please provide a copy of the Medicare card

Proof of eligibility in CHIP/Children’s Medicaid Program - Please provide a copy of the Medicaid card

Section A — Member information

Name: First, MI, Last, Suffix (Jr., III, etc.)

Police Officer

Social Security Number

Fire Fighter

Street / P.O. Box

Date of Birth

New address

City, State, ZIP Code

Gender:

Male

Female

Alternate telephone

E-mail address

Home telephone

Marital status (Do not mark single if you are divorced)

Marriage date

Divorce date

Single

Married

Widowed

Divorced

It is extremely important that you and your dependents enroll in Medicare when you become first eligible. If you or your

enrolled dependents fail to enroll in Medicare Parts A or B when you are first eligible, the OP&F–sponsored plan requires

UnitedHealthcare to process claims as if you or your dependent were Medicare eligible and you will be responsible for

all fees and expenses incurred that Medicare would have paid. In addition, OP&F reserves the right to recover any

reimbursements erroneously processed for these individuals by UnitedHealthcare.

Yes

Are you eligible for Medicare?

If yes, please attach a copy of your Medicare card when returning this form.

Yes

Aside from OP&F, is any other entity reimbursing you for your Medicare Part B premium?

If yes, who? ___________________________________________________________________________

Yes

Are you or any dependents enrolled in Medicare Part D drug coverage? If yes, please list their names and

effective enrollment dates: ____________________________________________________________________

Please attach proof of effective date.

Yes

Have you ever terminated Medicare Part D? If yes, please list the date of termination: _________________

Please provide a copy of your disenrollment letter.

Yes

Are you eligible for Medicaid?

If yes, please attach a copy of your Medicaid card when returning this form.

Page 1 of 4

2017 Health Care Eligibility and Enrollment Form

Form # 1010

Health Care Eligibility And Enrollment Form - 2017

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