New York Member Enrollment Form - Ohi (Page 2 of 2) in pdf

New York Member Enrollment Form – OHI

MAILING ADDRESS: P. O. Box 7085, Bridgeport CT 06601 • 1-800-444-6222 • www oxfordhealth com

A. Group Information (To be completed by the employer)

Please print neatly using black or blue ballpoint pen • ALL DATES MUST BE: MM/DD/YYYY

Group Number

Group Name

Plan CSP

Billing Group

Date of Hire

Effective Date

Occupation

COBRA/Young Adult/SC Qualifying

Event Date

Employer Signature

Date

■

On Leave of Absence

Retired

Event

■

Union Employee

Disabled

B. Applicant Details (To be completed by the employee)

Employee/Subscriber

Spouse

Child

Social Security Number:

Last Name:

First Name, Middle Initial:

Date of Birth: (MM/DD/YYYY)

■

Gender and Disability Status: (Check appropriate boxes.)

Disabled

Primary Care Physician (PCP) ID Number:

___________________________________

__________________________________

___________________________________

■

Yes

PCP Name: ( If an

of PCP, check “Yes”. )

existing patient

■

Full-time Student

■

Check all that apply:

Domestic Partner

■

Young Adult

Prior Carrier

Carrier:

___________________________________

(List coverage prior to this.)

Policy Number:

___________________________________

From Date

■

Same for all

Thru date::

C. Coordination of Benefits

Employee/Subscriber

Spouse

Child

■

Check appropriate

Part A

Medicare Coverage

■

box and list

Part B

■

effective date:

Part D

Pharmacy

Policy Number:

___________________________________

■

Same for all

Carrier:

___________________________________

Policy Holder:

___________________________________

Effective Date:

Group Number:

BIN:

PCN:

Policy Number:

___________________________________

Medical

Carrier:

___________________________________

■

Same for all

Policy Holder:

___________________________________

Effective Date:

understand

that

enrollments

and

benefits

are

accordance

with

those

described

the

Oxford

Health

Insurance

Certificate.

understand

that,

order

receive

in-network

benefits,

and

any

enrolled

dependents

must

seek

care

through

our

Oxford

affiliated

primary

care

physician or through an Oxford-affiliated specialist physician with an authorized referral from the primary care physician if required. I further understand that if I do not adhere to these requirements, I will be eligible only for out-of-network health insurance coverage under the terms of the Certificate. Any person who knowingly and with intent to defraud any insurance company or other person files an application

for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. I authorize any health provider or insurer to furnish

Oxford any records concerning me or any enrolled member of my family for whom information is requested.

Employee’s/Young Adult’s Address (Apt #)

Employee’s/Young Adult’s Signature

Date

________________________________________________________________________________________________________

City

State

Zip

OHINY MEF LS 1109

4318 REV 8