Enrollment Application/change/cancellation Request Form - Unitedhealthcare (Page 3 of 4) in pdf

D. 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)*

for other coverage

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)

Reason for Medicare eligibility:

Over 65

Kidney Disease

Disabled

Disabled but actively at work

Medicare – Spouse/Dependent Name: ____________________________________________

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)

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.

E. Waiver of Coverage

Declining coverage due to existence of other coverage:

I understand that by waiving coverage at this time,

I will not be allowed to participate unless I qualify at

I decline coverage for:

Spouse’s Employer’s Plan

Individual Plan

a special enrollment period or as a late enrollee, if

Myself

Covered by Medicare

Medicaid

applicable, or at the next open enrollment period.

Spouse

COBRA from Prior Employer

VA Eligibility

I acknowledge that I have received the “Important

Dependent Children

Tri-Care

Information” statement

Myself and all dependents

I (we) have no other coverage at this time

Employee Initials Date

which is included

Other ____________________________________

with this form.

F. Signature

I confirm that the information I have provided on this form is complete and accurate.

I understand that the health benefit plan that I have selected provides reimbursement for certain medical costs, which are more fully described

in the current Certificate of Coverage. I understand there may be instances where treatment decisions made by my physician or me or medical

expenses which I have incurred may not be covered by my health benefit plan.

I understand that information collected in connection with administration of the benefit plan may be used to bring to my attention health

products or services that might be valuable to me and otherwise as permitted by law. I understand that you may combine that information with

other information so that it is no longer individually identifiable and use it for commercial and other purposes.

I acknowledge that I have received the “Important Information” statement which is included on the back of this form.

Date

Employee Signature for all applying and waiving

Spouse Signature (if applying for coverage)

Primary Language Spoken

English

Spanish

Other ________________________________

I I

LG.EE.12.OR 9/12

Page 3 of 4

Enrollment Application/change/cancellation Request Form - Unitedhealthcare Page 3

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