Form Sg.ee.14.va - Employee Enrollment Form

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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
MI
Social Security Number
Address
Apt #
City
State
Zip Code
Home/Cell Phone
Date of Birth
Gender
Email Address
Work Phone
M
F
/
/
Do you use tobacco?
1
Yes
No
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
No
(If applicable)
Existing Patient?
Yes
No
2
Primary Care Physician
Physician First & Last Name
Address
I – I
ID#
I
I
I
I
I
I
I
I
I
I
I
I
(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)
Coverage:
Employee + Child(ren)
Employee Only
Employee + Spouse
Employee + Family
445-6719 5/14
SG.EE.14.VA 5/13
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