Fillable Medical Enrollment/termination/cobra Change Form (Page 3 of 4) in pdf

Instructions

Conditions of Enrollment - Applicant Acknowledgements and Agreements

Employers

On behalf of myself and the dependents listed in this Enrollment/Change Request form,

I acknowledge that:

You must complete the Group Information and sections A, B, and L in order for this

application to be processed.

1. I authorize any physician or medical professional, hospital, clinic or other medical

Employees

care institution, carrier, consumer reporting agency, and any employer to give

Horizon Blue Cross Blue Shield of New Jersey or Horizon Healthcare of

You must complete sections C through J and submit the signature of each Over-Age

New Jersey, Inc., or any consumer reporting agency acting on behalf of Horizon

Child for which a Dependent Under 31 Continuation Election is made in accordance

Blue Cross Blue Shield of New Jersey or Horizon Healthcare of New Jersey, Inc.,

with Section B in order for this application to be processed.

information pertaining to employment, other health coverage, and medical advice,

• Please PRINT except when a signature is requested.

treatment or supplies for any physical or mental condition relevant to me or a

• If a dependent is disabled and you want to continue his or her coverage beyond the

minor dependent applying for coverage. I agree that this authorization shall be

limiting age, you do not have to make a COBRA/NJSGC or Dependent Under 31

valid for 30 months from the date I sign this Enrollment/Change Request form,

election. Instead, select “Other” in Section A, and attach proof of disability.

unless revoked at an earlier date.

• You can obtain the providers’ correct names and addresses from the appropriate

2. I agree that, if I revoke this authorization before it expires, such revocation shall

provider directory. You may also obtain each provider’s NPI and LOC Code number

not affect any action that Horizon Blue Cross Blue Shield of New Jersey or

from the provider directory or at: Providers with multiple

Horizon Healthcare of New Jersey, Inc. has taken in reliance on the authorization.

office locations and individual providers who belong to more than one practice or

3. I understand I may receive a copy of this authorization if I request one.

provider entity may have more than one NPI number. You should confirm the correct

4. I agree Horizon Blue Cross Blue Shield of New Jersey or Horizon Healthcare

NPI number for the specific provider and office location where you will be seen

of New Jersey, Inc. will provide coverage in accordance with the terms of the

by contacting that office directly.

contract for the group plan/policy.

Qualifying Events

5. I agree that the provision of coverage and benefits is contingent upon payment of

COBRA and NJSGC

premiums and may be terminated in accordance with the terms of the group

plan/policy if premiums are not paid timely. I authorize my Employer to withhold

C1. Termination of job or reduction in hours

payments from my wages as contribution to the premium, as appropriate.

C2. Employee enrollment in Medicare (COBRA only)

Misrepresentations

C3. Divorce (COBRA/NJSGC); civil union dissolution (NJSGC) or termination of

Any person who includes any false or misleading information on an

domestic partnership (NJSGC)

Enrollment/Change Request Form for a health benefits plan is subject to criminal and

C4. Death of employee

civil penalties.

C5. Loss of dependent child status (aged out) under the plan.

C6. Disability (occurring subsequent to another qualifying event)

Dependent Under 31

D1. Loss of dependent status (aged out) and otherwise eligible

D2. Re-establish eligibility: residency

D3. Re-establish eligibility: nonresident full-time student

D4. Re-establish eligibility: change in marital status

D5. Re-establish eligibility: change in parental status

D6. Re-establish eligibility: termination of other coverage

D7. Other, w/proof of creditable coverage or receipt of benefits

Products and services provided by Horizon Blue Cross Blue Shield of New Jersey or Horizon Healthcare of New Jersey, Inc., each of

which is an independent licensee of the Blue Cross and Blue Shield Association.

Medical Enrollment/termination/cobra Change Form Page 3

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