Medical And/or Dental Application And Change Form printable pdf download

MEDICAL AND/OR DENTAL APPLICATION AND CHANGE FORM

Please use this form to enroll in or change your medical and/or dental coverage. Be sure to complete this entire form and retain the PINK copy to serve as

your temporary ID card if needed. If you only need to change your mailing address, do not complete this form; instead, call HealthTrust Enrollee Services at

800.527.5001 and notify your employer.

BE SURE TO FILL OUT EACH SECTION COMPLETELY. Include information on all your eligible family members at initial enrollment and when making changes.

Failure to complete each section in full could delay the start of coverage.

PRIMARY CARE PROVIDER (PCP) SELECTION

When you enroll in a BlueChoice

or Access Blue New England

medical plan, each member of your family must choose their own PCP to coordinate medical care. Your PCP can be a family or general practitioner, an internist,

or a pediatrician (for children). A Provider Directory can be accessed on-line at by clicking on “Resources.” Should you decide to change your PCP after initially enrolling with HealthTrust, do not fill out

this form. Instead, call the Anthem Member Services number on the back of your medical ID card.

DENTAL COVERAGE

• Dependent children are generally eligible for coverage as of the first of the month following their second birthday. In order for your children to be covered, you must enroll them at that time; coverage is not automatic.

• You are required to enroll for a 12-month period. Voluntary cancellations or membership downgrades are not allowed during this period unless you terminate employment, your dependent is no longer eligible, or you

experience a qualified family status change.

HOW TO COMPLETE THIS FORM

Remove this cover sheet before you begin

ENROLLEE (EMPLOYEE) INFORMATION

STEP

Complete this section with your personal information, using your full legal name. Select the type of HealthTrust-sponsored medical and/or dental coverage you are requesting and the membership type for each. Please limit

your selection to only those coverages offered by your employer and for which you are eligible. If you are applying for the Medicare Supplemental plan, please complete the Retiree Medical and/or Dental Application and

Change Form.

REASON FOR COMPLETING FORM

STEP

Use this section to indicate the reason(s) for completing form. If you are a current HealthTrust enrollee making a change to your existing membership, you must include the actual date of event. Please see your

employer or call HealthTrust to obtain additional forms that are required for divorce/legal separation or retirement.

ENROLLEE AND DEPENDENT INFORMATION

Complete this section as your membership should appear at HealthTrust. If you need additional space, use the Additional Dependent(s) Information section on the last page of this form.

STEP

• If you are enrolling a dependent child age 26 or older who is disabled, complete a Certification for a Mentally or Physically Disabled Child Over Maximum Age form available through your employer or at

. Your dependent child will not be added to your coverage until approval of incapacitated status has been received by HealthTrust.

• If your HealthTrust-sponsored medical plan requires a PCP, you must provide a PCP name and PCP ID number (including all characters) for you and each of your covered dependents; indicate if you are a current patient.

OTHER INSURANCE COVERAGE INFORMATION

STEP

Complete this section if you or a covered family member will have other coverage along with this plan or are transferring from another group medical or dental plan. If you choose to cover some, but not all of your

eligible dependents, proof of other group coverage for those dependents you are not covering may be required.

STEP

ENROLLEE SIGNATURE

Sign and date this form; return completed form to your employer.

EMPLOYER USE ONLY

STEP

Employer must review form and verify that steps 1-5 are completed. Employer must complete this section and forward to HealthTrust for processing at: PO Box 617, Concord, NH 03302; email to: enrolleeservices@healthtrustnh.org;

or fax to: 603.226.2988

Questions? Please call us at 800.527.5001, Monday through Friday, 8:30 a.m. to 4:30 p.m.

Form #HT035

Revision Date 3/16