New Jersey Small Employer - Member Enrollment/change Request Form - Ohi - 2014 Page 2
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4B. Employee Information – To be completed by the Employee (continued)
Add
Remove
Continuation
Other Change If a name change, indicate prior name:
Primary Name: _________________________________________________________ Provider #:
Current Patient:
Yes
No
Ob/Gyn Name: _________________________________________________________ Provider #:
Current Patient:
Yes
No
Other Health Coverage?
Yes
No
If yes: Payer Name: ____________________________________________________________ Policy #: ____________________________________________
Medicare ID#, if any: __________________________________________________
C. Plan Option - To be completed by the Employee
PPO Flex (Freedom Network)
Oxford PPO HSA (Freedom Network)
Oxford EPO HSA (Freedom Network)
PPO Flex (Liberty Network)
Oxford PPO HSA (Liberty Network)
Small Group:
Oxford EPO HSA (Liberty Network)
Oxford EPO (Freedom Network)
Gated EPO (Freedom Network)
Other Plan__________________
Oxford EPO (Liberty Network)
Gated EPO (Liberty Network)
D. Other Individuals Covered - To be completed by the Employee. Identify individuals other than yourself for whom you are adding/changing/removing/continuing
coverage. Attach additional pages if necessary, with your signature and dated. Attach proof of disability.
1.
Spouse
Domestic Partner(DP)
2. Child
3. Child
4. Child
Civil Union (CU) Partner
Add
Remove
Other
Add
Remove
Other
Continue
Add
Remove
Other
Continue
Continue Spouse
Add
Remove
Other
Continue
Continue Civil Union Partner (NJSGC)
Continue Domestic Partner (NJSGC)
Name (last, first, MI)
Name (last, first, MI)
Name (last, first, MI)
Name (last, first, MI)
L:_____________________________
L:_____________________________
L:_____________________________
L:_____________________________
F:_____________________________
F:_____________________________
F:_____________________________
F:_____________________________
MI:____________________________
MI:____________________________
MI:____________________________
MI:____________________________
Birthdate (mm/dd/yyyy):
Birthdate (mm/dd/yyyy):
Birthdate (mm/dd/yyyy):
Birthdate (mm/dd/yyyy):
______/______/_________
______/______/_________
______/______/_________
______/______/_________
Male
Female /
Disabled
Male
Female /
Disabled
Male
Female /
Disabled
Male
Female /
Disabled
Social Security Number:
Social Security Number:
Social Security Number:
Social Security Number:
Other Health Coverage:
Yes
No
Other Health Coverage:
Yes
No
Other Health Coverage:
Yes
No
Other Health Coverage:
Yes
No
If yes:
If yes:
If yes:
If yes:
Payer Name:_____________________
Payer Name:_____________________
Payer Name:_____________________
Payer Name:_____________________
Policy#:_________________________
Policy#:_________________________
Policy#:_________________________
Policy#:_________________________
Medicare ID#:____________________
Medicare ID#:____________________
Medicare ID#:____________________
Medicare ID#:____________________
Primary Care Provider:
Primary Care Provider:
Primary Care Provider:
Primary Care Provider:
Name:__________________________
Name:__________________________
Name:__________________________
Name:__________________________
Provider ID#:_____________________
Provider ID#:_____________________
Provider ID#:_____________________
Provider ID#:_____________________
Current Patient?
Yes
No
Current Patient?
Yes
No
Current Patient?
Yes
No
Current Patient?
Yes
No
OB/Gyn:
OB/Gyn:
OB/Gyn:
OB/Gyn:
Name:__________________________
Name:__________________________
Name:__________________________
Name:__________________________
Provider ID#:_____________________
Provider ID#:_____________________
Provider ID#:_____________________
Provider ID#:_____________________
Current Patient?
Yes
No
Current Patient?
Yes
No
Current Patient?
Yes
No
Current Patient?
Yes
No
If last name is different from Employee’s,
If last name is different from Employee’s,
If last name is different from Employee’s,
please explain:
please explain:
please explain:
Employed?
Yes
No
________________________________
________________________________
________________________________
If Yes, complete Section E1
________________________________
________________________________
________________________________
Home or billing address same as
Living with Employee
Yes
No
Living with Employee
Yes
No
Living with Employee
Yes
No
Employee?
Yes
No
If No, complete Section F
If No, complete Section F
If No, complete Section F
If No, complete Section E2
NJ-HINT-Group
OHI NJS MEF 6856 R12
2
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