Coordination Of Benefits Information

Coordination of Benefits Information ONLY:

Are you or any member of your family going to have health coverage in addition to this health plan?

Yes

No If yes, please

complete the following:

Name of covered members:

_________________________________________________________ Med Dent Vision _____/_____/______ Group / Individual

Member Name

Type of Coverage

Effect. Date

Circle Policy

_________________________________________________________

Name of Carrier

_________________________________________________________ Med Dent Vision _____/_____/______ Group / Individual

Member Name

Type of Coverage

Effect. Date

Circle Policy

_________________________________________________________

Name of Carrier

_________________________________________________________ Med Dent Vision _____/_____/______ Group / Individual

Member Name

Type of Coverage

Effect. Date

Circle Policy

_________________________________________________________

Name of Carrier

Provide the following information on the carriers listed above:

________________________________________ (_______)________-__________ ______________________________________

Carrier Name

Carrier Phone #:

Policy Number

____________________________________________________________________________________________________________

Street Address

Apt

City

State

Zip Code

________________________________________________________ _______________________________ _____/______/______

Subscriber Name

SS#

DOB

Employer Name (if group coverage)

Street Address

City

State

Zip Code

Marital Status:

Single

Married ______________________________________

Widowed

Legally Separated

Divorced

Name of Spouse

If divorced, is there a court order for provision of the child?

Yes

No

If yes, attach a copy of the court decree. Per the Court Decree:

Who has custody of child?____________________________Who needs to provide insurance for child?________________________

List the full name(s) of child(ren)_________________________________________________________________________________

List both natural parents: Nat. Father__________________DOB___________ Nat. Mother__________________DOB____________

Is employee, spouse/domestic partner coverd under this medical plan eligible for Medicare Benefits?

Yes

No

If yes, enter date of eligibility for Medicare Part A____/____/____ or for Part B ____/____/____ SS# __________________________

I certify that the above listed information is correct and that I am enrolling only eligible dependents as defined in the Plan Document. I understand that all entitlements to

benefits are void, and coverage may be canceled or modified retroactively to its effective date, if I have made intentionally false or misleading statements or answers on behalf

of myself or any family members. I authorize any person or institution providing care or services, or any organization in possession of insurance benefit information to release

any and all information pertaining to the care or benefits provided to me or my dependents to Healthcare Management Administrators or its designated agent.

I acknowledge and understand that 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: 1) A physician, dentist, pharmacist or other physical or behavioral health care

practitioner; 2) A clinic, hospital, long term care or other medical facility; 3) Any other institution providing care, treatment, consultation, pharmaceuticals or supplies; or 4) 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 psychotherapy notes. A separate authorization will be used for psychotherapy notes.

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

_____________________________________________________________________ _____________________________________

Employee’s Signature

Date Signed

_____________________________________________________________________ _____________________________________

Employee Printed Name

Social Security #