Fillable Form Sg.ee.14.va - Employee Enrollment Form printable pdf download

Employee Enrollment Form

• UnitedHealthcare of the Mid-Atlantic, Inc. (“The Company”)

[800 King Farm Boulevard, Rockville, MD 20850]

To speed the enrollment process, please be thorough and fill out all sections that apply.

Group Name

Requested Effective Date of Coverage/Date of Change

To Be Completed by Employer

Group Name

Policy Number

Pro-Sphere Tek

907171

Reason for Application:

New Hire

Date of Hire

Employee Type: (Check all that apply)

Annual Open

New Group Plan

Active

Life Event/Date: ________

Enrollment

COBRA Start dt: ___________

Position/Title

Status Change

Termination

Cobra End dt: ________State: _______

Dependent: Add/Delete

Hours Worked per week

Name/Address Change

Hourly

Salary

Part time to Full time

Retired

Waiving Coverage

Other: ________________________

Other: _______________________

A. Employee Information

If you are waiving all coverage, please complete sections A and F.

Last Name

First Name

Social Security Number

Address

Apt #

City

State

Zip Code

Home/Cell Phone

Date of Birth

Gender

Email Address

Work Phone

Do you use tobacco?

Yes

Marital Status:

Single

Married

Divorced

Widowed

If yes, are you currently participating in a tobacco cessation program or

Language Preference, if not English ___________________________

do you intend to join one?

Yes

(If applicable)

Existing Patient?

Yes

Primary Care Physician

Physician First & Last Name

Address

I – I

ID#

(1) Tobacco means all tobacco products, including, but not limited to, cigarettes, cigars, and chewing tobacco. You should only check the “yes” box above if

tobacco was used four or more times per week on average (excluding religious or ceremonial use) within the past 6 months by someone of legal age to

purchase tobacco in the state of residence. (2) For UnitedHealthcare Compass, Navigate, Select, Select Plus, and other products requiring you to choose a

Primary Care Physician (PCP), you must use the UnitedHealthcare directory of providers to choose a PCP for yourself and each of your covered dependents.

(3) Please see employer representative as some dental plans require a Primary Care Dentist (PCD) selection. (4) For court ordered dependent, legal

documentation must be attached. If a dependent does not reside with eligible employee, please provide address on a separate sheet. (5) If you answered “Yes”

for Disabled and the dependent child is 26 years of age or older, unmarried, chiefly dependent upon subscriber for support and is not able to be self-

supporting because of a physically or mentally disabling injury, illness or condition, please attach a medical certification of disability.

Coverage Provided by “UnitedHealthcare and Affiliates”:

Medical coverage provided by UnitedHealthcare Insurance Company or UnitedHealthcare of the Mid-Atlantic, Inc. or UnitedHealthcare Plan of the River

Valley, Inc. or Optimum Choice, Inc. or MD-Individual Practice Association, Inc.

Please select one box for coverage in which you or your dependents are enrolling.

Benefit offerings are dependent upon employer selection.

B. Coverage Selection

Waiving Coverage

Standard Plan

Premium Plan

Basic Plan

(not available for employee only)