Fillable Employee Enrollment Change Form - New Mexico Health printable pdf download

EMPLOYEE ENROLLMENT/CHANGE FORM

Employer Name:

Department/Location:

New Enrollee:  Effective Date: _____/_____/ _____

Enrollment Changes:  Subscriber ID# _______________________

Date of Hire/Reinstated: ____/____/_____

COBRA Yes  No 

Variable Hour Employee? Yes  No 

Hours Worked Per Week:

Are you waiving your employer’s group coverage? Yes,  I hereby waive New Mexico Health Connections medical coverage. Complete Step 2 below, then sign and date form.

Reason for Waiver: Individual exchange plan 

Individual off-exchange plan 

Another Employer Group Plan 

Medicare/Medicaid 

Other Coverage 

Not Covered 

STEP 1: ENROLLMENT EVENTS/CHANGES

Open Enrollment? No  Yes  (if Yes, then skip to Step 2) Special Enrollment Event? No  Yes , date: ____/____/____

Adding a Dependent? No  Yes  Marriage  Birth, Adoption, Placement for Adoption or Foster Care  Court Order  Loss of other coverage  Other: __________________________

Termination of policy  OR Termination of dependent Name:________________________ Termination Date:____/____/_____ Reason: Terminated  Divorce 

Death 

Other: __________________

STEP 2: EMPLOYEE INFORMATION

Last Name:

First Name:

MI:

Social Security Number (SSN):

DOB: ____/ _____/ _____

Home Address:

Apt./Ste: City:

State:

ZIP:

Mailing Address (if different then above):

Apt./Ste: City:

State:

ZIP:

Gender/Sex: M  F 

E-mail Address:

Primary Phone: (

)

Other Phone: (

)

Ethnicity/Race: American Indian/Alaskan Native 

Asian or Pacific Islander 

Black or African American Hispanic  White  Multiracial 

Do you or any of your dependents prefer a spoken or written language other than English? Yes  No 

Do you or any of your dependents require assistance due to a disability? Yes  No 

If yes, please list here:

If yes, please describe:

STEP 3: PLAN INFORMATION

Your selection will be limited to the benefit plans made available to you by your employer. Any benefit discrepancies will default to the benefit plan offering selected by your employer. Please review the information in your

enrollment materials or check with your benefits coordinator if you are uncertain about the types of benefit plans available to you. Your coverage election will be the health benefit selection made by your employer.

If your employer offers multiple NMHC plans, select your coverage: HMO  or PPO 

Coverage applied for: Employee only  2-Party  Employee + Child(ren) Family 

Plan Name: __________________________________________________________________

STEP 4: DEPENDENT INFORMATION

Last Name

First Name

M.I.

SSN

Date of Birth

Gender/Sex

M 

F 

Legal Spouse/Domestic Partner

M 

F 

Child

M 

F 

Child

M  F 

Child

Will you or any other family member listed above continue to be covered by any other insurance company? Yes  No 

Insurance Company:

List name(s):

Do you or any family member listed above have Medicare? Yes  No 

Part A  Part B 

Member Name:

Medicare Number:

STEP 5: SIGN AND DATE

READ PAGE 2 OF THIS APPLICATION. By signing this application, I attest that I have read both sides of this application and warrant my current and continuing authority to act on behalf of and fully bind all of the above Dependents

with respect to every provision of the NMHC Evidence of Coverage. If you have questions, please call our Help Center at 1-855-7MY-NMHC (855-769-6642), Monday through Friday from 8 a.m. to 5p.m.

Employee Signature

Date

Employer Signature

Date

ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION

IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES.

NMHC0344-0815