Form Sg.ee.14.tn - Employee Enrollment - 2013 (Page 3 of 4) in pdf

Employee Name __________________________________________________________________________________________________________

D. Prior Medical Insurance Information

Within the last 12 months, have you, your spouse, or your dependents had any other medical coverage?

YES (if yes, please complete this section.)

Prior medical carrier name ____________________________________________________ Effective date ___/___/___ End date ___/___/___

Prior coverage type:

Employee

Spouse

Child(ren)

Family

E. Other Medical Coverage Information

This section must be completed. (Attach sheet if necessary.)

On the day this coverage begins, will you, your spouse or any of your dependents be covered under any other medical health plan or policy,

including another UnitedHealthcare plan or Medicare?

YES (continue completing this section)

NO (skip the rest of this section)

Name of other carrier ______________________________________________________

Other Group Medical Coverage Information

Type

Effective Date End Date

Name and date of birth of policyholder

(only list those covered by other plan)

(B/S/F)*

MM/DD/YY

for other coverage

Employee:

Spouse Name:

Dependent Name:

*B. Enter ‘B’ when this dependent is covered under both you and your spouse’s insurance plan (married)

S. Enter ‘S’ if you are the parent awarded custody of this dependent and no other individual is required to pay for this dependent’s medical expenses.

F. Enter ‘F’ if this dependent is covered by another individual (not a member of your household) required to pay for this dependent’s medical expenses.

Medicare – Employee Information:

If enrolled in Medicare, please attach a copy of your Medicare ID card.

Enrolled in Part A: Effective Date _____________

Ineligible for Part A*

Not Enrolled in Part A (chose not to enroll)**

Enrolled in Part B: Effective Date _____________

Ineligible for Part B*

Not Enrolled in Part B (chose not to enroll)**

Enrolled in Part D: Effective Date _____________

Ineligible for Part D*

Not Enrolled in Part D (chose not to enroll)**

Reason for Medicare eligibility:

Over 65

Kidney Disease

Disabled

Disabled but actively at work

Are you receiving Social Security Disability Insurance (SSDI)?

YES

Start Date ___ /___ /___

Medicare – Spouse/Dependent Name: ____________________________________________

Enrolled in Part A: Effective Date _____________

Ineligible for Part A*

Not Enrolled in Part A (chose not to enroll)**

Enrolled in Part B: Effective Date _____________

Ineligible for Part B*

Not Enrolled in Part B (chose not to enroll)**

Enrolled in Part D: Effective Date _____________

Ineligible for Part D*

Not Enrolled in Part D (chose not to enroll)**

Reason for Medicare eligibility:

Over 65

Kidney Disease

Disabled

Disabled but actively at work

*Only check “Ineligible” if you have received documentation from your Social Security benefits that indicate that you are not eligible for Medicare.

** If you are eligible for Medicare on a primary basis (Medicare pays before benefits under the group policy), you should enroll in and maintain

coverage under Medicare Part A, Part B, and/or Part D as applicable.

Declining coverage due to existence of other coverage:

F. Waiver of Coverage

I understand that by waiving coverage at this time, I

Spouse’s Employer’s Plan

Individual Plan

will not be allowed to participate unless I qualify at a

I decline all coverage for:

Covered by Medicare

Medicaid

special enrollment period or as a late enrollee, if

Myself

COBRA from Prior Employer

VA Eligibility

Spouse

applicable, or at the next open enrollment period.

Tri-Care

Dependent Children

I (we) have no other coverage at this time

Myself and all dependents

Other ____________________________________

Date

Employee Signature if waiving coverage

Page 3 of 4

Form Sg.ee.14.tn - Employee Enrollment - 2013 Page 3

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