Fillable Member Enrollment Form - Tufts Health Plan printable pdf download

MEMBER ENROLLMENT FORM

Please print clearly or type. Please be sure application is completed in full to ensure enrollment. Employers can mail completed forms to: Tufts Health Plan • P.O. Box 9186 • Watertown, MA 02471-9186

FAILURE TO COMPLETE AREAS MARKED IN BLUE WILL CAUSE A DELAY IN ENROLLMENT.

EMPLOYER SECTION

WSHG - Town of Wellesley

41130-130

Group/Company

Name________________________________________________________________________

Group

Number_______________________________________________________

Office Location________________________________________

Date of

Hire____________________________________

Effective Date of

Coverage____________________________________

Type of Enrollment:

New Hire

Open Enrollment

COBRA

New Group

Qualifying Event (MUST

specify)___________________

Qualifying Event

Date______________________________

❏

MEMBER SECTION

PRODUCT (Select corresponding letter from the list on the front page) _________ Other _______________________________________

Last

Name_________________________________________________

First

Name_________________________________________

Middle

Initial______

Primary

Language________________________

Employee Social Security Number

_______________________________

Date of Birth

(MM/DD/YYYY)_______ / _______ / _______________

Gender:

❏

Male

❏

Female

(required)

Mailing (Home)

Address___________________________________________________ City_______________________________ State_____ ZIP___________ Home Telephone ( ____ ) ______________

Marital Status:

❏

Single

❏

Married

❏

Divorced

❏

Domestic Partner

Type of Coverage Requested:

❏

Individual

❏

Family

❏

Other______________________ Work Telephone ( ____ ) ______________

Primary Care Provider

___________________

_____________________________

PCP ID#

_______________

Are you an established patient of this PCP?

❏

Yes

❏

(HMO, POS, EPO only) First Name

Last Name

Members Enrolling

Sex

Date of Birth

Social Security Number

Choose a Primary Care Provider for each

Check

PCP ID #

(First name, include last name if different)

M/F

(MM/DD/YEAR)

member (HMO, POS, EPO only. Include first

if currently

and last name.)

used for

primary care

❏ Spouse

❏

❏ Domestic Partner

Child/Dependent

❏

Child/Dependent

❏

Child/Dependent

❏

Child/Dependent

❏

Child/Dependent

❏

Please check if you are using additional membership applications for additional dependent children. ❏

Do you or someone else covered under this insurance policy have other health insurance coverage at the same time your Tufts Health Plan policy is in effect? ❏ Yes

❏ Yes (Medicare)

❏ No

Name of Health Plan_____________________________________________ Name of Plan Holder___________________________________ Health Plan Number____________________ Effective Date______________________

Names of Family Members Covered___________________________________ Is Spouse Employed? ❏ Yes ❏ No

If Yes, Name and Address of Employer _____________________________________________________________

The information supplied on this form is true and complete. I authorize my employer to make necessary payroll deductions, if any, for my share of Tufts Health Plan coverage. I assign benefits to Tufts Health Plan providers, which means that Tufts Health Plan is autho-

rized to make payments directly to Tufts Health Plan providers for services rendered to me (us). I grant Tufts Health Plan any legal right that I (we) may have to recover the cost of services for an illness or injury caused by someone else when these services have been or

will be paid by Tufts Health Plan. I understand that calls to the Member Services department may be monitored for quality assurance. I understand that the benefits for which I (we) are eligible are those described in the applicable member benefit documents.

Signature

(required)_____________________________________ Date____________

Benefits Dept.

Signature__________________________________ Telephone__________________________ Date____________

WHITE - TUFTS HEALTH PLAN COPY

PINK - EMPLOYER COPY

YELLOW - SUBSCRIBER COPY. Please keep yellow copy as your temporary Tufts Health Plan ID.