Dental Reimbursement Plan Qualifying Event Form - Decatur County Board Of Education printable pdf download

Decatur County Board of Education

Dental Reimbursement Plan Qualifying Event Form

Employee Name: ____________________________________________________________________________________

Employee SS#: __________/___________/___________

Employee D/O/B: ___________/___________/___________

Address: __________________________________________________________________________________________

City: __________________________________________________ State: ______________ Zip: ____________________

Home/Cell Phone: __________-__________-__________

Work Phone: __________-__________-__________

School/Work Location: _________________________________ E-Mail: _______________________________________

Please choose the appropriate option below:

I choose to ADD/ DROP the following

Employee/Single Coverage

Family Coverage

Dependent(s) due to a Qualifying Event

$10.00

$30.00

(Please mark coverage option as well)

Please list below the dependents you are dropping due to a qualifying event:

Spouse:

__________________________________

D/O/B: _______/_______/_______ SS#: _______/______/_______

Dependent: _________________________________ D/O/B: _______/_______/_______ SS#: _______/_______/_______

HIPPA: This form is used to authorize, the DCBOE, and its agents, or employees, to use or disclose your protected Health Information (PHI) to the administrator, or

employee’s to administrate our DR Dental Plan. We will use your information for service, billing questions, claims, letters, and to provide your benefits to you. This

authorization is at the request of the individual and will expire as of your termination of employment with the DCBOE. You have the right to revoke this

authorization at any time by giving written notice of my revocation to the County Office. I understand that revocation of this authorization will not affect any action

you took in reliance on this authorization before you received my written notice of revocation. I have had full opportunity to read and consider the contents of this

authorization, and I understand that by signing this form, I am confirming my authorization of the use/or disclosure of my protected health information as described

in this form.

Do you have other Dental Insurance?

Yes

If yes, name of other company: ________________________________________________________________________________

Address: _________________________________________________________________________________________________

City: _____________________________________________ State: _________________ Zip: _____________________________

Policy Number: ____________________________________________________________________________________________

I elect or decline coverage offered to me by the DCBOE Dental DR Plan as marked above during open enrollment.

I hereby authorize my employer, until this

authorization is revoked by written notice, to deduct each month from any earned or accrued wages due me, the amount applicable to the coverage I have

selected. I hereby certify that the above information and any attachments thereto are true and correct. I understand misrepresentation or falsification will subject

me to penalties and possible legal action.

Employee Signature: __________________________________________ Date: ___________/___________/__________