Extended Coverage/cobra Change Request Form-Commonwealth Of Virginia Health Benefits Program (Page 2 of 2) in pdf

PARt C: Requesting Changes to Plan

Indicate plan in which qualified beneficiary/ies are requesting enrollment (based on reason indicated in Part B).

StAtEwIdE HEALtH PLAnS

COVA Care (with preventive dental) (ACC0)

COVA HealthAware (with preventive dental) (CHA)

COVA Care + Out of Network (ACC1)

COVA HealthAware + Expanded Dental (CHA2)

COVA Care + Expanded Dental (ACC2)

COVA HealthAware + Expanded Dental & Vision (CHA1)

COVA Care + Out of Network and Expanded Dental (ACC3)

COVA HDHP - High Deductible Plan (with preventive dental) (CHD)

COVA Care + Expanded Dental + Vision & Hearing (ACC4)

COVA HDHP - High Deductible Plan + Expanded Dental (CHD1)

COVA Care + Out of Network + Expanded Dental +

Vision & Hearing (ACC5)

REgIOnAL HEALtH PLAn

Kaiser Permanente HMO- available in Northern Virginia, Central Virginia and Northern Neck designated zip codes (KP)

Other _______________________________________________________________

FAMILy MEMBERS tO BE COvEREd

(list all to be covered, not just additions)

NAME

BIRTHDATE

SOCIAL SECuRITY

PLEASE PRINT (include last name if different)

MM/DD/YYYY

NuMBER

Former Employee

Spouse

Children

If you need more space, attach a separate sheet of paper to this form.

PARt d: Certification

EnROLLEE StAtEMEnt: I want to make a change in Extended Coverage/COBRA enrollment. I understand that I will be billed directly for the monthly

premium. Once enrolled, I understand that changes may only be made at Open Enrollment or with certain qualifying midyear events (see Part B) when

the changes are consistent with the events. I have read and understand my rights and responsibilities as explained in my Election Notice. I understand that

my premiums are subject to change and that the Commonwealth of Virginia reserves the right to change my coverage to the appropriate plan and membership

based on my eligibility and/or plan availability just as those requirements apply to similarly-situated Non-Extended Coverage/COBRA health plan participants.

I understand that non-payment of premium will result in cancellation of coverage per the provisions of the Public Health Service Act as described in my

Election Notice and that claims will not be processed during the defined grace period until premium is paid.

CERtIFICAtIOn/AutHORIzAtIOn: I certify that I have reviewed the information on this enrollment form and that it is complete and accurate to the

best of my knowledge. Furthermore, I understand that the health plan and its business associates have the right to use Protected Health Information in

connection with the treatment, payment and operations of these plans as defined by the Health Insurance Portability and Accountability Act.

Print Name ______________________________________________________________________________ Social Security Number ______________________________

Sign Here _______________________________________________________________________________ Date ______________________________________________

Return this form to: Office of Health Benefits Extended Coverage/COBRA Administrator

101 North 14th Street, 13th Floor

Richmond, VA 23219

FOR OHB COBRA AdMInIStRAtOR uSE

Change processed/effective date _____________________________________________

Change denied

OHB Staff Member ______________________________________ Date _________________

Extended Coverage/cobra Change Request Form-Commonwealth Of Virginia Health Benefits Program Page 2

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