Fillable Form Sg.ee.14.va - Employee Enrollment Form (Page 3 of 4) in pdf

Employee Name: _____________________________

D. Prior Medical Insurance Information

Within the last 12 months, have you, your spouse, or your dependents had any other medical coverage?

YES (if yes, please complete this section.)

End date

Prior medical carrier name:

Effective date

Prior coverage type:

Employee

Spouse

Child(ren)

Family

E. Other Medical Coverage Information

This section must be completed. (Attach sheet if necessary.)

On the day this coverage begins, will you, your spouse or any of your dependents be covered under any other medical health plan or

policy, including another UnitedHealthcare plan or Medicare?

YES (continue completing this section)

NO (skip the rest of this

section) Name of other carrier:

Other Group Medical Coverage Information

Type

Effective Date

End Date

Name and date of birth of policyholder

(only list those covered by other plan)

(B/S/F)*

MM/DD/YY

for other coverage

Employee:

Spouse Name:

Dependent Name:

*B. Enter ‘B’ when this dependent is covered under both you and your spouse’s insurance plan (married)

S. Enter ‘S’ if you are the parent awarded custody of this dependent and no other individual is required to pay for this dependent’s medical expenses.

F. Enter ‘F’ if this dependent is covered by another individual (not a member of your household) required to pay for this dependent’s medical expenses.

Medicare – Employee Information:

If enrolled in Medicare, please attach a copy of your Medicare ID card.

Enrolled in Part A: Effective Date

Ineligible for Part A*

Not Enrolled in Part A (chose not to enroll)**

Enrolled in Part B: Effective Date

Ineligible for Part B*

Not Enrolled in Part B (chose not to enroll)**

Enrolled in Part D: Effective Date

Ineligible for Part D*

Not Enrolled in Part D (chose not to enroll)**

Kidney Disease

Over 65

Disabled

Disabled but actively at work

Reason for Medicare eligibility:

No Start date

Are you receiving Social Security Disability Insurance (SSDI)?

YES

Medicare – Spouse/Dependent Name:

Not Enrolled in Part A (chose not to enroll)**

Enrolled in Part A: Effective Date

Ineligible for Part A*

Not Enrolled in Part B (chose not to enroll)**

Enrolled in Part B: Effective Date

Ineligible for Part B*

Not Enrolled in Part D (chose not to enroll)**

Enrolled in Part D: Effective Date

Ineligible for Part D*

Reason for Medicare eligibility:

Over 65

Kidney Disease

Disabled

Disabled but actively at work

*Only check “Ineligible” if you have received documentation from your Social Security benefits that indicate that you are not eligible for Medicare.

** If you are eligible for Medicare on a primary basis (Medicare pays before benefits under the group policy), you should enroll in and maintain

coverage under Medicare Part A, Part B, and/or Part D as applicable.

Declining coverage due to existence of other coverage:

F. Waiver of Coverage

I understand that by waiving coverage at this time, I

Individual Plan

will not be allowed to participate unless I qualify at a

Spouse’s Employer’s Plan

I decline all coverage for:

Medicaid

special enrollment period or as a late enrollee, if

Covered by Medicare

Myself

applicable, or at the next open enrollment period.

COBRA from Prior Employer

VA Eligibility

Spouse

Tri-Care

Dependent Children

I (we) have no other coverage at this time

Myself & all Children

Other: ___________________________

Employee Signature if waiving coverage

Date

Page 3 of 4

Form Sg.ee.14.va - Employee Enrollment Form Page 3

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