Enrollment Application/change/cancellation Request Form - Unitedhealthcare Page 2
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4B. Family Information
List All Enrolling/Changing/Cancelling (Attach sheet if necessary)
Check
Last Name
First Name
MI
Physician*(First and Last Name)
Sex Relationship**
Birthdate
appropriate
Physician’s ID Number
Social Security Number
box
Enroll
M
Spouse
Cancel
F
Change
Race – Check all that apply (Optional)***
Primary Care Dentist Number*
American Indian/Alaska Native
Asian
Black/African-American
Hispanic/Latino
Native Hawaiian/Pacific Islander
White
Other–Please specify _____________________
Enroll
M
Dependent
Cancel
F
Change
Race – Check all that apply (Optional)***
Primary Care Dentist Number*
American Indian/Alaska Native
Asian
Black/African-American
Hispanic/Latino
Native Hawaiian/Pacific Islander
White
Other–Please specify _____________________
Enroll
M
Dependent
Cancel
F
Change
Race – Check all that apply (Optional)* **
Primary Care Dentist Number*
American Indian/Alaska Native
Asian
Black/African-American
Hispanic/Latino
Native Hawaiian/Pacific Islander
White
Other–Please specify _____________________
Enroll
M
Dependent
Cancel
F
Change
Race – Check all that apply (Optional)***
Primary Care Dentist Number*
American Indian/Alaska Native
Asian
Black/African-American
Hispanic/Latino
Native Hawaiian/Pacific Islander
White
Other–Please specify _____________________
Enroll
M
Dependent
Cancel
F
Change
Race – Check all that apply (Optional)***
Primary Care Dentist Number*
American Indian/Alaska Native
Asian
Black/African-American
Hispanic/Latino
Native Hawaiian/Pacific Islander
White
Other–Please specify _____________________
* IMPORTANT: Please see employer representative as some plans require a Primary Physician (Primary Care) and/or a Primary Care
Dentist (PCD) selection.
** For some cases, such as Qualified Medical Child Support, additional documentation may be required. Please see employer representative
for more information.
*** Data collected will be used only to help communicate with enrollees and inform them of specific programs to enhance their well-being
and not for eligibility or claim payment determination.
C. Product Selection
Please check all that apply. Benefit offerings are dependent upon employer selection.
Dual Option Plan
Selected
Person
Medical
Dental
Vision
Life/Amount
Sup Life Sup AD&D
STD
LTD
Employee
I I
I I
I I
I I
$____________
I I
I I
I I
I I
Spouse
I I
I I
I I
I I
Dependents
I I
I I
I I
I I
Salary __________
Required only if Life
Plan based on salary
Life Insurance Beneficiary’s Full Name and Address
Relationship
LG.EE.12.OR 9/12
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Parent category: Medical