Enrollment, Change And Declination Form printable pdf download

City:

State:

Zip:

Cell Phone Number:

Home Email:

Sex: ☐ M ☐ F

Language:

☐ Other

Ethnicity:

Phone Number:

Phone

Enrollment, Change and Declination Form

(If no to both, you are not

Are you an active employee and making monthly contributions to TRS? ☐ Yes

☐ No

eligible for TRS

ActiveCare

ELIGIBILTY:

If no, are you regularly scheduled to work 10 or more hours per week? ☐ Yes

☐ No

coverage)

SECTION 1: ENROLLMENT/CHANGE TRANSACTION TYPE

□

☐ New Employee

☐ Add Dependent

☐ Special Enrollment

For District Use Only

Annual Enrollment

TRS District #

□

For New Employee (check one):☐Effective on Actively at Work ☐Effective 1

day of month following

Actively at Work Date:

Effective/Change Date:

☐Marriage

☐Court Order

☐Birth/Adoption

Special Enrollment Event Date: __ /__ /____

☐ Loss of Coverage

☐Other

Change Only:

Decline Coverage:

Employer Approval:

Cancel Employee

Cancel Dependent

☐Yes (Complete Section 6)

☐Death

☐Divorce

☐ Name

☐N/A

☐Loss of Eligibility

☐Death

☐Retirement/Terminated

☐Loss of Eligibility

☐Address

Effective Date of Change/Cancel

Were you covered by another

☐Non-Payment

☐Dropped Coverage

district? ☐ Yes ☐ No

☐Plan/Coverage

_____ / _____ / _________

☐Other: _____________

☐Other: ____________

If so, which: _______________

SECTION 2: EMPLOYEE INFORMATION

Last Name:

First Name:

MI:

Social Security #:

Mailing Address:

City:

State:

Zip:

Residence Address:

City:

State:

Zip:

Home Phone Number:

Cell Phone Number:

Email:

Sex: ☐M ☐F

Language: ☐ English

☐Spanish

Date of Birth:

Ethnicity:

☐Yes (Please complete Section 8)

☐ No

Do you have a disability affecting your ability to communicate or read?

☐Yes Carrier/Plan:

☐No

Is the Employee Covered By Other Insurance?

Is the Employee Covered by Medicare? ☐Yes

☐Part A

☐Part B

☐Part C

☐Part D

☐No

Effective:

☐ Entitlement Age

☐ Disability

☐End Stage Renal Disease (ESRD)

Reason for Medicare Coverage:

SECTION 3: COVERAGE SELECTION (Please select a Plan of Coverage – Plan or HMO - and Coverage Type)

☐ActiveCare 1-HD

☐ActiveCare Select

☐ActiveCare 2

Plan Selection:

HMO Selection: ☐FirstCare Health Plans

☐Scott & White Health Plan

☐Allegian Health Plans

(formerly Valley Baptist Health Plans)

Coverage Type Selected: ☐Employee Only

☐Employee + Spouse

☐Employee + Child(ren)

☐Employee + Family

SECTION 4: DEPENDENT INFORMATION (Use additional form for additional dependents)

SPOUSE Last Name:

First Name:

MI:

☐Same as Employee

Street Address:

City:

State:

Zip:

Phone Number:

Sex: ☐M ☐F

Date of Birth:

Social Security #:

Other Insurance: ☐Yes. Carrier/Plan

☐No

☐Medicare: ☐Part A

☐Part B

☐Part C

☐Part D

MI:

CHILD Last Name:

First Name:

☐Natural/Adopted

☐Stepchild

☐Foster Child

☐Grandchild

☐Legal Guardian ☐Disabled

☐ Other

☐Same as Employee

Street Address:

City:

State:

Zip Code:

Phone Number:

Sex: ☐M

☐F

Social Security #:

Date of Birth:

Other Insurance: ☐Yes. Carrier/Plan

☐No

☐Medicare: ☐Part A

☐Part B

☐Part C

☐Part D

MI:

CHILD Last Name:

First Name:

☐Natural/Adopted

☐Stepchild

☐Foster Child

☐Grandchild

☐Legal Guardian

☐Disabled

☐ Other

☐Same as Employee

Street Address:

City:

State:

Zip Code:

Phone Number:

Sex: ☐M ☐F

Social Security #:

Date of Birth:

Other Insurance: ☐Yes. Carrier/Plan

☐No

☐Medicare: ☐Part A

☐Part B

☐Part C

☐Part D

PLEASE CONTINUE ON NEXT PAGE

Enrollment, Change And Declination Form

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