Employee Enrollment Form Page 2
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4Employee Name __________________________________________________________________________________________________________
C. Family Information
List All Enrolling (Attach sheet if necessary)
Last Name
First Name
MI
Sex
Date of Birth
Relationship
4
M
F
/
/
Social Security Number
Do you use tobacco?
1
Yes
No If yes, are you currently participating
Spouse
in a tobacco cessation program or do you intend to join one?
Yes
No
Primary Care Physician
2
Existing Patient?
Yes
No
Primary Care Dentist
3
Existing Patient?
Yes
No
Physician First & Last Name _________________________________
Dentist First & Last Name __________________________________
Address _________________________________________________
ID# ___________________________________________________
ID# ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ – ___ ___ ___ ___
Last Name
First Name
MI
Sex
Date of Birth
Relationship
4
M
F
/
/
Social Security Number
Do you use tobacco?
1
Yes
No If yes, are you currently participating
Dependent
in a tobacco cessation program or do you intend to join one?
Yes
No
Primary Care Physician
2
Existing Patient?
Yes
No
Primary Care Dentist
3
Existing Patient?
Yes
No
Physician First & Last Name _________________________________
Dentist First & Last Name __________________________________
Address _________________________________________________
ID# ___________________________________________________
ID# ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ – ___ ___ ___ ___
Permanently disabled and age 26 or older
5
Yes
No
Last Name
First Name
MI
Sex
Date of Birth
Relationship
4
M
F
/
/
Social Security Number
Do you use tobacco?
1
Yes
No If yes, are you currently participating
Dependent
in a tobacco cessation program or do you intend to join one?
Yes
No
Primary Care Physician
2
Existing Patient?
Yes
No
Primary Care Dentist
3
Existing Patient?
Yes
No
Physician First & Last Name _________________________________
Dentist First & Last Name __________________________________
Address _________________________________________________
ID# ___________________________________________________
ID# ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ – ___ ___ ___ ___
Permanently disabled and age 26 or older
5
Yes
No
Last Name
First Name
MI
Sex
Date of Birth
Relationship
4
M
F
/
/
Social Security Number
Do you use tobacco?
1
Yes
No If yes, are you currently participating
Dependent
in a tobacco cessation program or do you intend to join one?
Yes
No
Primary Care Physician
2
Existing Patient?
Yes
No
Primary Care Dentist
3
Existing Patient?
Yes
No
Physician First & Last Name _________________________________
Dentist First & Last Name __________________________________
Address _________________________________________________
ID# ___________________________________________________
ID# ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ – ___ ___ ___ ___
Permanently disabled and age 26 or older
5
Yes
No
Last Name
First Name
MI
Sex
Date of Birth
Relationship
4
M
F
/
/
Social Security Number
Do you use tobacco?
1
Yes
No If yes, are you currently participating
Dependent
in a tobacco cessation program or do you intend to join one?
Yes
No
Primary Care Physician
2
Existing Patient?
Yes
No
Primary Care Dentist
3
Existing Patient?
Yes
No
Physician First & Last Name _________________________________
Dentist First & Last Name __________________________________
Address _________________________________________________
ID# ___________________________________________________
ID# ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ – ___ ___ ___ ___
Permanently disabled and age 26 or older
5
Yes
No
(1) Tobacco means all tobacco products, including, but not limited to, cigarettes, cigars, and chewing tobacco. You should only check the “yes” box above if
tobacco was used four or more times per week on average (excluding religious or ceremonial use) within the past 6 months by someone of legal age to
purchase tobacco in the state of residence. (2) For UnitedHealthcare Compass, Navigate, Select, Select Plus, and other products requiring you to choose a
Primary Care Physician (PCP), you must use the UnitedHealthcare directory of providers to choose a PCP for yourself and each of your covered dependents.
(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. (5) If you answered “Yes”
for Disabled and the dependent child is 26 years of age or older, unmarried, chiefly dependent upon subscriber for support and is not able to be self-
supporting because of a physically or mentally disabling injury, illness or condition, please attach a medical certification of disability.
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