Enrollment/change Form - Schnectady Office

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Enrollment/Change Form
ACTION REQUESTED: D Enroll
SCHENECTADY
D Change
OFFICE
D Cancel
TO BE COMPLETED BY EMPLOYER
Group #
Subgroup #
Effective Date
Product #
Product #
Employee Class
Employee Dept. (if applicable)
Approved by
1
INFORMATION ABOUT YOURSELF
INSTRUCTIONS TO EMPLOYEE: Please print or type and complete Sections 1 through 5.
D Single
D Married
Employee Name (Last, First, Initial, Suffix)
Marital Status
Address
City
State
Zip
County
D Active D Retiree
Phone
Employer
Date Employed
D Yes
Coverage D Individual
If yes, by
Spouse’s health
Do you or any other family
Spouse’s health insurance
members have health insurance ? D No
D Family
whom?
carrier (if other than yours)
level
insurance ID#
Eligible for Medicare? D Yes D No
Employee ID#
Spouse ID#
D A Effective Date
D B Effective Date
D A Effective Date
D B Effective Date
Employee
Spouse
2
3
ENROLLMENT/CHANGE
For address or Primary Care Physician changes, call 1­800­318­8575 or visit
CHOOSE COVERAGE
D New Applicant
D Termination
D HMO*
D EPO
D TriVantage
Reason:
:
(choose an option)
A
B
D Name Change
D New Hire
D Remove Dependent(s) only
D PPO
D Healthy NY*
D Active Lifestyles
(please specify)
D COBRA
D Open Enrollment
D Indemnity
D Prescription Drug Only
D Family Focus
D Add Dependent
D COBRA/State Continuation
D Dental
D High Deductible EPO
D Healthy Alternatives
Reason:
D Plan Transfer
D Qualifying Event
D Termination of Employment
D Opting for Other Coverage
D POS*
D High Deductible PPO
(describe) ____________________________
D Address Change
D Other __________________________________________
D Moved From Area
D Other _________________
*Please choose a Primary Care Physician—for each family member—in Section 4.
4
If you are applying for HMO, POS or Healthy NY coverage, you and each of your dependents
INFORMATION ABOUT ALL FAMILY MEMBERS YOU WANT ENROLLED UNDER YOUR PLAN
must designate your choice of Primary Care Physician in order for MVP to initiate coverage.
self
1. Name (First, MI, Last)
Relationship to Employee
D Male D Female
Date of Birth ____ ____ / ____ ____ /____ ____
Social Security No. ___ ___ ___ – ___ ___ – ___ ___ ___ ___
Primary Care Physician (PCP) (First, Last)
PCP Number
spouse/civil union partner
Domestic Partner
D
D
2. Name (First, MI, Last)
Relationship to Employee
D Male D Female
Date of Birth ____ ____ / ____ ____ /____ ____
Social Security No. ___ ___ ___ – ___ ___ – ___ ___ ___ ___
Primary Care Physician (PCP) (First, Last)
PCP Number
Check all that apply: D Disabled D Current Patient D Full­time Student over 18
3. Name (First, MI, Last)
Relationship to Employee
D Male D Female
Date of Birth ____ ____ / ____ ____ /____ ____
Social Security No. ___ ___ ___ – ___ ___ – ___ ___ ___ ___
If applicable: College Name
Primary Care Physician (PCP) (First, Last)
PCP Number
Expected Graduation Date
Check all that apply: D Disabled D Current Patient D Full­time Student over 18
4. Name (First, MI, Last)
Relationship to Employee
D Male D Female
Date of Birth ____ ____ / ____ ____ /____ ____
Social Security No. ___ ___ ___ – ___ ___ – ___ ___ ___ ___
If applicable: College Name
Primary Care Physician (PCP) (First, Last)
PCP Number
Expected Graduation Date
For additional dependents, please list on a separate form.
5
I have read and agree to the authorization of the reverse side of this form.
Late entrant?
D
Yes
D
No
SIGNATURE
SIGNATURE____________________________________________________________________________________________DATE ______________________
MVP COMMERCIAL ENROLL FORM (5/09)

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