Dental Application And Change Form

DENTAL APPLICATION AND CHANGE FORM

ENROLLEE (EMPLOYEE) INFORMATION

Last Name

First Name

MI

REASON FOR COMPLETING FORM

Mailing Address

City

State

Zip

❑ New Enrollee

❑ Dependent No Longer Eligible

❑ Benefit Change

S

S

Telephone

Email

❑ Open Enrollment

Dependent Name

T

T

❑ Retirement

❑ Name Change

Employer Name

Social Security #

E

E

❑ Retiree or Spouse Now Medicare Eligible

❑ Marriage

P

P

❑ Loss of Other Coverage (explain)

❑ Birth/Adoption

Is your position covered by a collective bargaining agreement? ❑ Yes ❑ No

❑ Death

TYPE OF COVERAGE AND MEMBERSHIP REQUESTED (check)

If yes, check the appropriate category:

❑ Election of COBRA Coverage

❑ Divorce/Legal Separation

2

1

❑ Teacher ❑ Police ❑ Fire ❑ Public Works ❑ Other

❑ Other (explain)

Dental Membership

Marital Status

Dental Type

❑ Single

❑ Married

❑ Other ______________________

Actual Date of Event

❑ Widowed

❑ Divorced/Legally Separated

Dental Option #_____

❑ Single

❑ Two-Person

❑ Family

ENROLLEE AND DEPENDENT INFORMATION (Complete this section as your membership should appear)

Date of Birth

HealthTrust Office Use Only

NAME (First, MI, Last)

Relation to Enrollee

Gender

Month/Day/Year

Employee Name

____/____/____

Self

❑ Male

❑ Female

S

Spouse Name

T

❑ Male

❑ Female

____/____/____

Spouse

E

Spouse Email

P

Dependent Child Name**

❑ Male

❑ Female

____/____/____

3

Dependent Child Name**

❑ Male

❑ Female

____/____/____

Dependent Child Name**

❑ Male

❑ Female

____/____/____

**If you are enrolling a dependent child age 26 or older who is disabled, complete a Certification for a Mentally or Physically Disabled Child Over Maximum Age form available through your employer or at

OTHER DENTAL INSURANCE COVERAGE INFORMATION

Name of Insurance Company

S

Do you or your family have dental coverage through another group or employer?

❑ Yes

❑ No

T

Policy Number

E

Are you or another dependent transferring coverage from another dental carrier?

❑ Yes

❑ No

P

Effective Date

Termination Date

Member Name

4

ENROLLEE SIGNATURE

S

I hereby authorize HealthTrust and my employer to institute the enrollment(s) indicated on this form. If my employer requires a contribution for this coverage, this authorizes the appropriate payroll deductions. I understand that the effective date and termination date of my membership

T

will be determined by HealthTrust and my employer in accordance with the plan rules. I understand that I must sign this form for claims to be processed. By signing this application, I attest to the accuracy and truthfulness and will provide documentation to HealthTrust upon request.

E

I understand that any misrepresentation affecting the above named Enrollee’s and/or Dependents’ eligibility may result in retroactive cancellation of the dental coverage and any charges incurred will be my liability. I understand it is my responsibility to notify my employer immediately

P

when any Dependent no longer meets eligibility requirements of the plan.

5

Enrollee Signature________________________________________________________________________________________________________________________________________________Date ____/____/____

EMPLOYER USE ONLY

Date of Hire ____/____/____

Date of Rehire ____/____/____

❑ Full-Time

❑ Part-Time to Full-Time Date ____/____/____

❑ Part-Time Number of Hours Weekly_______________

❑ COBRA

❑ Retiree

S

T

Eligibility Organization Name

Employee Job Title

E

P

Benefits Administrator Signature/Stamp

Dental Group/Carrier Number

6

Effective Date of Coverage ____/____/____

Date ____/____/____

Form #HT037

White - HealthTrust

Yellow - Employer

Pink - Employee

Revision Date 9/15