Medical Enrollment/termination/cobra Change Form
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Attn: Small Group Enrollment
P.O. Box 607 Department A
GROUP ENROLLMENT/CHANGE REQUEST
Newark, NJ 07101-0607
Fax (973) 274-2227
C. Employee Information – to be completed by Employee.
Group Information – to be completed by Employer.
Group Name: ____________________________________ Group Number: ___________________
ADD
REMOVE
CONTINUATION
OTHER CHANGE
If a name change, indicate prior name: __________________________________________________
Sub Group Number: ____________________________________
Enrollment of a new Subscriber
Date of Hire: _____/_____/_____ Effective Date/Date of Event: _____/_____/_____
Last Name, First Name, M.I. __________________________________________________________
Reason for Change: _______________________________________________________________
Social Security# ____________________________ Date of Birth ______/______/_____ Sex _______
A. Type of Activity – to be completed by Employer.
Home Address _________________________________________Apt ______ City ______________
Refer to instructions before completing this form. Print clearly.
ADD
REMOVE
OTHER CHANGE
Effective Date/Date of Event
Reason for Change
State ______ Zip Code __________ Home Phone ________________ E-Mail Address _____________
Spouse
_______/_______/_______ ________________
Civil Union Partner (CUP)/Domestic Partner (DP)
_______/_______/_______ ________________
Employer Name ________________________________________ Employment Date ____/____/____
Dependent Child
_______/_______/_______ ________________
Hours Worked
Employer Address ______________________________________ City ___________ Per Week ______
Over-Age Child as a Dependent Under 31
_______/_______/_______ ________________
(please complete coverage continuation section and section B, if applicable)
State ______ Zip Code __________ Work Phone ________________ E-Mail Address ______________
Name Change
_______/_______/_______ ________________
Change Plan
_______/_______/_______ ________________
Primary Care Provider Name ___________________________________ Current Patient
Yes
No
Other
_______/_______/_______ ________________
NPI # ________________________________ Loc Code _____________________________________
COVERAGE CONTINUATION
For Employee Billing:
Group
Other Health Coverage
Yes
No, If yes, Payer Name ____________________________________
Date of Loss of Coverage
Qualifying Event #**
Date of Qualifying Event
_____/_____/_____
________________
_____/_____/_____
Policy # _____________________________ Medicare ID #, If any _____________________________
Total Disability*
COBRA/NJSGC
Length of Continuation (in months):
18
29
*Attach proof of disability
Previous Coverage
Yes
No, If yes, Payer Name _______________________________________
For Spouse/Civil Union Partner*/Domestic Partner Billing:
Group
Date of Loss of Coverage
Qualifying Event #**
Date of Qualifying Event
Policy # _______________________ Effective Date ____/____/____ Termination Date ____/____/____
_____/_____/_____
________________
_____/_____/_____
COBRA/NJSGC
Length of Continuation (in months):
18
29
36
Submit a copy of the Certificate of Creditable Coverage
*Civil union partners are eligible to make an election pursuant to NJSGC, if applicable.
For Dependent or Over-aged Child Billing:
Group
D. Race/Ethnicity – to be completed by the Employee, at his/her option.
Date of Loss of Coverage
Qualifying Event #**
Date of Qualifying Event
NOTE: Your response is appreciated but NOT required!
Choose a category that most closely describes you:
_____/_____/_____
________________
_____/_____/_____
COBRA/NJSGC
Length of Continuation (in months):
18
29
36
American Indian or Alaskan Native
Black, not of Hispanic origin
Dependent Under 31 Billing:
Home
Hispanic
Asian or Pacific Islander
White, not of Hispanic origin
Date of Loss of Coverage
Qualifying Event #**
Date of Qualifying Event
_____/_____/_____
________________
_____/_____/_____
E. Plan Option – to be completed by the Employee.
Home Address: ________________________________________________________________
Check one Coverage Option Box and one Plan Option Box
**Qualifying event #s: see list in Instructions.
Medical
S
F
H/W
CUP
DP
P/C
Dental
S
F
H/W
CUP
DP
P/C
B. Additional Information for Dependent Under 31 Continuation Elections.
Prescription
S
F
H/W
CUP
DP
P/C
Provide information below about children listed in Section F for whom a Dependent Under 31 continuation election is being made.
Horizon Advantage EPO
This Continuation Election is being made:
Horizon Traditional
Horizon Direct Access
Horizon Direct Access (HSA)
During Continuous Open Enrollment for Dependent Under 31 elections
Horizon POS
Horizon PPO (HSA)
Horizon PPO
Within 30 days prior to the attainment of the limiting age (when the Dependent will become an
Horizon HMO
Horizon HMO (HSA)
Prescription
Other ___________
Over-Age Child)
S = Single F = Family H/W = Husband/Wife CUP = Civil Union Partners DP = Domestic Partners
P/C = Parent/Child(ren)
The Employee Copy of this application may be used as a temporary ID card for 30 days from the effective date if authorized by Employer. Coverage must be verified with Horizon Blue Cross Blue Shield of
New Jersey or Horizon Healthcare of New Jersey, Inc. prior to visiting a physician or admission to a hospital.
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