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

New York Member enrollment Form – OHP

MAILING ADDRESS: P.O. Box 29142, Hot Springs, AR 71903 • 1-800-444-6222 •

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

Young Adult

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::

Employee/Subscriber

spouse

child

C. Coordination of Benefits

Check appropriate

Part A

Medicare Coverage

Part B

box and list

effective date:

Part D

Pharmacy

Policy Number:

___________________________________

Same for all

Carrier:

■

___________________________________

Policy Holder:

___________________________________

effective date:

Group Number:

BIN:

PCN:

Policy Number:

___________________________________

Medical

___________________________________

Carrier:

■

Same for all

Policy Holder:

___________________________________

Effective Date:

A. 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 receive HMO benefits, I and any enrolled dependents must seek care through our Oxford affiliated primary care physician or through an Oxford-affiliated specialist physician with an authorized referral

from the primary care physician if required. 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. Any person who knowingly and with 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.

B. I understand that in addition to the applicable Oxford Health Plans (NY) Inc. HMO Certificate, my enrollment and benefits are in accordance with those described in the applicable Oxford Health Insurance, Inc. Supplemental Freedom Plan Certificate. I understand that, in order to receive HMO benefits, I and any enrolled dependents must seek care through our Oxford

affiliated primary care physician or through an Oxford-affiliated specialist physician with an authorized referral from the primary care physician if required. I further understand that if I do not adhere to these requirements for HMO benefits, I will be eligible only for traditional health insurance coverage under the terms of the Oxford Health Insurance, Inc. Supplemental Freedom Plan Certificate.

Any person who knowingly and with 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 code

OHPNY MEF LS 1109 05-2013

333 REv 13

UHCNY632402-001