Enrollment Application & Change Of Information Form (Page 2 of 2) in pdf

SECTION 7

Other insurance

Coordination of beneﬁts

Will employee or any dependents have other insurance?

Yes

SECTION 8

Dependent(s) not living with employee

Are any of the dependent(s) not living with the employee? If yes, please provide the state and ZIP code.

Dependent name

State

ZIP

Dependent name

State

ZIP

Dependent name

State

ZIP

Dependent name

State

ZIP

**A child is eligible for coverage if he/she meets the dependent eligibility requirements of the employee’s plan. See your Member Handbook for details.

The following are eligible dependent children:

• Your natural child

• Your step-child or adopted child

• Children placed with you for adoption

• Newborns born to a covered dependent, for whom you are ﬁnancially responsible (legal guardianship is required for coverage after the ﬁrst 31 days)

• Children related by blood or marriage for whom you are the legal guardian. (You will need to attach a signed court order showing legal guardianship)

• Your domestic partner’s natural child or adopted child (if applicable to your employer plan)

• Your Registered domestic partner’s natural child or adopted child (if applicable to your employer plan)

SECTION 9

Authorization

Please read and sign below.

I acknowledge and understand my health plan may request or disclose health information about me or my dependents (persons who are listed for beneﬁts coverage on

the enrollment form) from time to time for the purpose of facilitating health care treatment, payment or for the purpose of business operations necessary to administer

health care beneﬁts; or as required by law.* Health information requested or disclosed may be related to treatment or services performed by:

• A physician, dentist, pharmacist or other physical or behavioral health care practitioner;

• A clinic, hospital, long term care or other medical facility;

• Any other institution providing care, treatment, consultation, pharmaceuticals or supplies or;

• An insurance carrier or group health plan.

Health information requested or disclosed may include, but is not limited to: claims records, correspondence, medical records, billing statements, diagnostic imaging

reports, laboratory reports dental records, or hospital records (including nursing records and progress notes).

This acknowledgement does not apply to obtaining information regarding HIV/AIDS, Psychotherapy Notes, Alcohol/Drug and Genetic Testing. A separate

authorization will be used for information related to these health conditions.

* For more information about such uses and disclosures, including uses and disclosures required by law, please refer to the Notice of Privacy Practices. A copy is

available by calling the Privacy Ofﬁce at 503-243-4492.

I certify that the information provided on this form is true and correct to the best of my knowledge. I acknowledge that my enrollment form will be delayed if all

ﬁelds

with an asterisk are not ﬁlled out

entirely.

*Signature date

*Employee signature

5626306 (11/13) BE-1485

Insurance products in Oregon provided by Moda Health Plan, Inc. Health plans in Washington provided by Moda Health Plan, Inc.