Medical Enrollment/termination/cobra Change Form Page 2
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4G. Preexisting Conditions – to be completed by Employee.
F. Other Individuals Covered – to be completed by Employee.
Complete if you are a new enrollee except when enrolling in a Small Employer Group health benefits plan with more than 5 employees.
Identify individuals other than yourself for whom you are adding/changing/removing/ continuing coverage. Attach additional pages if
Complete for all late enrollees. If you check one of the conditions in #1, or respond yes to any question in #2, give details on a
necessary, with your signature and dated. Attach proof of disability.
separate sheet of paper. This separate sheet must be signed and dated by you. This information may ONLY be used to determine
if a condition is a pre-existing condition. You CANNOT be denied coverage under a health benefits plan on the basis of accurate
SPOUSE/CUP/DP
ADD
REMOVE
CONTINUE SPOUSE (COBRA/NJSGC)
responses to the following questions. Carriers may only use the information to expedite the processing of claims.
CONTINUE CU PARTNER (NJSGC)
CONTINUE DP /NJSGC)
1. If you or any dependent to be covered has been diagnosed as having any of the following
within the past 6 months, please place a check mark in the appropriate box:
Last Name, First Name, M.I. __________________________________________________________
a. Alcoholism or Drug Abuse
f.
Diabetes
k. Lung or Respiratory Disorder
b. Arthritis
g. Gastro or Intestinal Disorder
l.
Mental or Nervous Disorder
Social Security# ____________________________ Date of Birth ______/______/_____ Sex _______
c. Blood Disorder
h. Heart Disorder/Condition/Chest
m. Paralysis, Stroke or Epilepsy
Pain
d. Back or Neck Disorder,
Primary Care Provider Name _________________________________ Current Patient
Yes
No
Injury or Pain
i.
High Blood Pressure
e. Cancer or Tumors
j.
Kidney or Liver Disorder
2. During the past 6 months, have you or any dependent to be covered:
Yes
No
NPI # ________________________________ Loc Code _____________________________________
a. been examined or treated by a physician or other health care provider for
any condition, illness or injury, other than as stated above?
Other Health Coverage
Yes
No, If yes, Payer Name ____________________________________
b. been advised to have treatment or surgery or testing that has not been done?
c. been admitted to a hospital or other health care facility as an inpatient?
Policy # _____________________________ Medicare ID #, If any _____________________________
d. taken prescribed medication?
Previous Coverage
Yes
No, If yes, Payer Name _______________________________________
H. Additional Spouse/CUP/DP Information – to be completed by Employee.
If not applicable mark as N/A.
Employer Name ______________________________________ Employer Phone ________________
Policy # _______________________ Effective Date ____/____/____ Termination Date ____/____/____
Employer Address ___________________________________________________________________
Employed?
Yes
No If yes, Complete Section H1
City __________________________________________ State __________ Zip Code ______________
Submit a copy of the Certificate of Creditable Coverage
1. Child
ADD
REMOVE
CONTINUATION
OTHER CHANGE
I. Additional Child Information – to be completed by Employee.
Last Name, First Name, M.I. _________________________________________________________
Provide information below about children listed in Section F, if they have a different address from the employee. If multiple children are
at an address, you may list them together. Attach additional pages as necessary, signed and dated.
Social Security# ___________________________ Date of Birth ______/______/_____ Sex _______
Name _____________________________________________________________________________
Primary Care Provider Name ________________________________ Current Patient
Yes
No
Address ________________________________________________________________ Apt ________
NPI # _______________________________ Loc Code _____________________________________
City __________________________________________ State __________ Zip Code ______________
Reason: _________________________________________________________________________
Other Health Coverage
Yes
No, If yes, Payer Name ___________________________________
Name _____________________________________________________________________________
Policy # _____________________________ Medicare ID #, If any _____________________________
Address ________________________________________________________________ Apt ________
Previous Coverage
Yes
No, If yes, Payer Name ______________________________________
City __________________________________________ State __________ Zip Code ______________
Policy # ______________________ Effective Date ____/____/____ Termination Date ____/____/____
Reason: _________________________________________________________________________
If last name is different from Employee’s, please explain: ___________________________________
J. Employee Signature
Living with Employee?
Yes
No
If no, Complete Section I
I represent that all the information supplied in this application is true and complete. I hereby agree to the
Submit a copy of the Certificate of Creditable Coverage
Conditions of Enrollment set forth in this Enrollment/Change Request form. I authorize deductions from
2. Child
my earnings for any contributions required from me.
ADD
REMOVE
CONTINUATION
OTHER CHANGE
Signature: _________________________________________________________ Date: ___/___/___
Last Name, First Name, M.I. _________________________________________________________
K. Over-Age Child’s Signature
Social Security# ___________________________ Date of Birth ______/______/_____ Sex _______
I represent that all the information supplied in this application regarding the Dependent Under 31
Primary Care Provider Name ________________________________ Current Patient
Yes
No
Continuation Election is true and complete.
I hereby agree to the Conditions of Enrollment set forth in this Enrollment/Change Request form.
NPI # _______________________________ Loc Code _____________________________________
I hereby agree to make premium payments required from me for the Dependent Under 31 Continuation
Other Health Coverage
Yes
No, If yes, Payer Name ___________________________________
Election.
Policy # _____________________________ Medicare ID #, If any _____________________________
Signature: ________________________________________________________ Date: ___/___/___
L. Employer Verification
Previous Coverage
Yes
No, If yes, Payer Name ______________________________________
Policy # ______________________ Effective Date ____/____/____ Termination Date ____/____/____
The requested activity is believed eligible and is approved by the Employer:
Yes
No
If last name is different from Employee’s, please explain: ___________________________________
Employer Representative: ____________________________________________ Date: ___/__/___
Living with Employee?
Yes
No
If no, Complete Section I
Representative’s Title: ______________________________________________________________
Submit a copy of the Certificate of Creditable Coverage
PAGE 2
6803 (W08/11)
WHITE COPY - ENROLLMENT
YELLOW COPY - SALES
PINK COPY - EMPLOYER
GREEN COPY - EMPLOYEE
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