Enrollment Application & Change Of Information Form
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1
2Moda Health use only
Enrollment application &
Group number ______________________________
change of information form
Subscriber number __________________________
Medical and dental (100+)
*Group/employer
*Group ID
*Subgroup ID or name
*Class
I
I
I
SECTION 1
Coverage
SECTION 2
Type of application
SECTION 4
Add dependent(s)
New enrollment or rehire, Effective date: _______ /_______ /____________
Please select a qualifying event from the list below if the
Medical coverage
dependent addition is not due to open enrollment, new
Open enrollment
Dental coverage
hire or rehire.
Term dependent, Effective date: _______ /_______ /____________
Newborn birth
Reason: __________________________________________________________________
Adoption placement
(List dependent(s) to term in dependent section)
(adoption paperwork required with enrollment)
COBRA/Continuation, Effective date: _______ /_______ /____________
Court appointed guardian (court order of
Reason: __________________________________________________________________
legal guardianship is required with enrollment)
Loss of group coverage
(Certificate of Creditable Coverage required)
I
SECTION 3
Changes
Marriage (marriage certificate required with enrollment)
Domestic partner affidavit
(domestic partner affidavit required with enrollment)
Address change
Oregon Registered Domestic Partner (Registered
(please write new address in the Employee information section of this form)
Domestic Partnership Certificate required with enrollment)
Name change Old name: _________________________________________________
New name: ________________________________________________
Date of qualifying event: _______ /_______ /____________
I
SECTION 5
Employee information
Please complete this form and sign on the back. Please type or print legibly in ink. Thank you!
*Employee first name
M.I.
*Employee last name
*Employee Social Security number
*Employee mailing address
*City
*State
*ZIP
Home phone
*Date of birth (mm/dd/yyyy)
*Gender
*Date of employment (mm/dd/yyyy)
M
F
Primary language:
Email address
English
Spanish
Other ___________________________________
I
SECTION 6
Dependents
**List only eligible dependent children. See reverse side of form for dependent children qualifications.
Relationship code: SP = spouse, DP = domestic partner, RDP = Registered Domestic Partner (DP and RDP only if applicable to your plan)
*Date of birth
Primary language
Add
Term
Med
Den
*Dependent first name
M.I.
*Last
*Gender *Relationship
(mm/dd/yyyy)
(if different from employee)
Spouse
M
DP
F
RDP
M
Child**
F
M
Child**
F
M
Child**
F
M
Child**
F
Ward
*Spouse/DP/RDP Social Security number
Spouse/DP/RDP email address
*Enrollment will be delayed if fields with an asterisk are not filled out.
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