Form Pgc-Or Sm Enroll - Enrollment/change Of Status/waiver Form - 2015 Page 2

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Section 3 - Additional and/or creditable coverage information

(This section is not a waiver of coverage. This information is required for payment of claims.)

Do you or your family members have additional group health insurance and/or Medicare?

❏

YES

❏

If YES, check the types of coverage, then complete the information below:

❏

Medical

❏

Prescription drug

❏

Vision

Name of policyholder: ____________________________________________________ Policyholder’s date of birth: ______________________________________________

Insurance carrier: ________________________________________________________ Policy number: _________________________ Effective date of policy: _________

Carrier phone number: ___________________________________________________ Full names of persons covered: ___________________________________________

Is the insurance of any above dependents affected by a divorce decree / court order?

❏

YES

❏

If YES, please include portion of decree that shows responsibility for medical expenses.

❏

Have you had prior Providence Health Plan health coverage?

YES

NO If YES, please list previous member ID number: ___________________________

❏

Do you or any family members listed on this application have a Certificate of Creditable Coverage?

YES

If Yes, please complete the Other Insurance Coverage information above and attach a copy of your Certificate of Creditable Coverage with this application.

Section 4 - Waiver of coverage information

(Please include the names of all eligible members who will NOT be enrolling with Providence Health Plan.)

Type of coverage

Person(s) waiving

(individual/employer

Health plan name

Policy number

Employer group name

group/Medicare)

Notice: If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance coverage, you may, in the future, be able to enroll yourself or your dependents

in this plan, provided that you request enrollment within 30 days after your other coverage ends. In addition, if you have a new dependent as a result of marriage, birth, adoption or placement for adoption, you

may be able to enroll yourself and your dependents, provided that you request enrollment within 30 days after marriage, birth, adoption or placement for adoption.

Accuracy of enrollment information: Any person who, with an intent to knowingly defraud, files this application with materially false information or conceals material information,

may be subject to criminal and civil penalties and Providence Health Plan may cancel such person’s membership and refuse to pay their claims.

Subscriber acknowledgement: I acknowledge and understand that Providence Health Plan may request or disclose health information, other than psychotherapy notes, about me

or my dependents (persons who are listed for benefits coverage on the enrollment form) for the purpose of: (a) performing the health plan business operations of Providence Health Plan;

(b) facilitating health care treatment; (c) issuing or facilitating payment for health care services; or (d) as required by law. The use or disclosure of psychotherapy notes by Providence Health

Plan is restricted to circumstances in which the patient has provided a signed authorization.

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 at

or by calling customer service.

Payroll deduction authorization: I authorize my employer to deduct the required contributions from my pay for the coverage requested in this enrollment form. This authorization

applies to such coverage until I rescind it in writing. (Does not apply to COBRA, state continuation or waiver of coverage.)

Signature: ____________________________________________________________________________________________ Date: _______________________________

HP15-90330