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

ODS Enrollment Application

It is VERY important that the employee sign and date below. Thank you!

Covered Dependent Children Definition

An unmarried child is eligible for coverage if he/she meets the dependent eligibility requirements of the

employees 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)

Please read and sign below.

I acknowledge and understand my health plan may request or disclose health

Health information requested or disclosed may include, but is not limited to:

information about me or my dependents (persons who are listed for benefits

claims records, correspondence, medical records, billing statements, diagnostic

coverage on the enrollment form) from time to time for the purpose of facilitating

imaging reports, laboratory reports dental records, or hospital records (including

health care treatment, payment or for the purpose of business operations

nursing records and progress notes).

necessary to administer health care benefits; or as required by law.* Health

information requested or disclosed may be related to treatment or services

This acknowledgement does not apply to obtaining information regarding

performed by:

HIV/AIDS, Psychotherapy Notes, Alcohol/Drug and Genetic Testing. A separate

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

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

practitioner;

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

* For more information about such uses and disclosures, including uses and

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

disclosures required by law, please refer to the Notice of Privacy Practices. A

supplies or;

copy is available by calling the Privacy Office at 888-447-8187.

• An insurance carrier or group health plan.

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 the red

fields are not filled out entirely.

* X

* Date:

801283 (02/09)

Enrollment Application And Change Of Information Form Page 2

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