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

Healthy New York Member Enrollment Form

Mailing Address: Healthy New York Department, 14 Central Park Drive, Hookset, NH 03106 • 1-800-216-0778

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

■

Part A

Check appropriate

Medicare Coverage

■

box and list

Part B

■

effective date:

Part D

Pharmacy

Policy Number:

___________________________________

■

Same for all

Carrier:

___________________________________

Policy Holder:

___________________________________

BIN:

Effective Date:

Group Number:

PCN:

Policy Number:

___________________________________

Medical

Carrier:

___________________________________

■

Same for all

Policy Holder:

___________________________________

Effective Date:

I understand that my enrollment and benefits are in accordance with those described in the applicable Oxford Health Plans (NY), Inc. HMO Certificate. I understand that, in order to qualify for HMO benefits, I and any enrolled dependents must choose an Oxford affiliated physician for primary care and secure a referral from that

physician to an Oxford-affiliated specialist physician for all specialist care. I authorize any health provider or insurer to furnish Oxford Health Plans (NY), Inc. any records concerning me or any enrolled member of my family for whom information is requested. A photographic copy of this authorization shall be valid as the original.

I understand that any person who knowingly and with the 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

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

Employee’s/Young Adult’s Signature

Date

________________________________________________________________________________________________________

City

State

Zip

OHP HNY MEF 1010

4524 R6