Form Ahp-Ef2 - Gap Scholar Health Insurance Enrollment Form - Bcbs Form Page 2
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2UNIVERSITY OF TEXAS SYSTEM 2015-2016
101464-15 - Medical | 106145-15 - Dental
GAP SCHOLAR HEALTH INSURANCE ENROLLMENT FORM
Visiting Scholars and their Dependents
Scholar Name: _________________________________________
UT EID: ________________________________
(must be provided to be processed)
The scholar and/or spouse MUST be enrolled in the medical coverage to be eligible to enroll in the optional adult dental coverage. The scholar and
spouse must enroll in the same plan and coverage period.
*Optional Adult Dental coverage is only available to the scholar and spouse. Children that are under the age of 19 have pediatric dental benefits
under the medical plan. The rate shown for children is the Medical Only rate. If you are a scholar that has turned 19, you are eligible to purchase the
Adult Dental Plan by completing a Student Only Dental Qualifying Event Enrollment Form, available online at .
PLEASE CHECK ALL APPROPRIATE BOXES:
UT Arlington
UT El Paso
UT MD Anderson
UT Rio Grande Valley
UT Tyler
Campus
UT Austin
UT HSC Houston
UT MB Galveston
UT San Antonio
UT Dallas
UT HSC San Antonio
UT Permian Basin
UT Southwestern Medical Center
**Coverage Dates Requested: _________/_________/_________ through _________/_________/_________
**Coverage will extend 31 days from the effective date noted above, and may not extend past the termination date of your campus policy year.
GAP RATE
CALCULATE GAP RATE
Coverage:
Medical Only
Medical + Dental
Example: $182 x 3 months = $546
Scholar
$
182.00
$
203.00
$_______ X _______ = $_________
Rate
# Months
Total
Spouse
$
512.00
$
533.00
$_______ X _______ = $_________
Rate
# Months
Total
$
282.00*
Children
$
282.00
$_______ X _______ = $_________
)
(Medical only
Rate
# Months
Total
Total Amount Due:
$
PAYMENT INFORMATION: Make check or money order payable to Blue Cross and Blue Shield of Texas in U.S. dollars, or refer to the
charge card authorization to charge your premium to Visa, MasterCard, or Discover. Mail this enrollment form, along with premium payment, to
Academic HealthPlans, P.O. Box 1605, Colleyville, TX 76034-1605, or fax to (817) 809-4701 if paying by credit card. If you have questions,
please call Academic HealthPlans at (855) 247-7587. Your cancelled check or credit card billing is your only receipt and notification of coverage.
PAYMENT OPTIONS
Charge Full Amount
Check made
Blue Cross and Blue
$
via Card
payable to
Shield of Texas
/
Expiration
VISA
MasterCard
Discover
Check Amount
$
_____
_____
Date
Month
Year
Credit Card Number
Check Number
q By signing this form, I hereby authorize Academic HealthPlans to initiate a credit card transaction for the payment of my premium.
I understand my insurance will be cancelled if my credit card is declined. All charges will show on my credit card statement as
Academic HealthPlans, Inc.
SIGNATURE OF CARDHOLDER: ________________________________________________________
DATE: _______________
PRINTED NAME OF CARDHOLDER: _____________________________________________________
DATE: _______________
AHP-EF2(15) UTSYSTEM
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