Fillable Enrollment Form - Missouri Consolidated Health Care Plan printable pdf download

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Missouri Consolidated Health Care Plan

Submit this form:

MCHCP Use Only

573-751-0771 · 800-487-0771 ·

Online: Upload through myMCHCP

832 Weathered Rock Court, Jefferson City, MO 65101

Fax: 866-346-8785

ST ENR

Enroll/Change/Cancel

Mail: PO Box 104355

Jefferson City, MO 65110-4355

State Members

Please print clearly

Section 1 – Subscriber Information

Name (Last, First, Middle Initial):

MCHCPid



New Name

(Provide either MCHCPid or Social Security Number)

_________________________________________________________________________________________

___ ___ ___ ___ ___ – ___ ___ ___ ___ ___

or Social Security Number:

Address:



New Address

___ ___ ___ – ___ ___ – ___ ___ ___ ___

_________________________________________________________________________________________

Date of Birth

City:

State:

ZIP Code:

(MM/DD/YYYY):

___ ___ / ___ ___ / ___ ___ ___ ___

_________________________________________________________

___________

___ ___ ___ ___ ___

County Where You Live:

Primary Phone Number: 

Email:



Home

Work

Cell

______________________________

( ___ ___ ___ ) ___ ___ ___ – ___ ___ ___ ___

_________________________________________________________

Gender:

Marital Status:

Date of Marriage

Secondary Phone Number: 

Home



Work



Cell

(MM/DD/YYYY):



Male

Female

Single

Married

Widowed

___ ___ / ___ ___ / ___ ___ ___ ___

( ___ ___ ___ ) ___ ___ ___ – ___ ___ ___ ___

Section 2 – Add, Cancel, Drop Dependent or Transfer Coverage

Retiree Only:



Add Coverage:

Drop Dependent:

Due to life event or loss of coverage

Give reason and date of occurrence

(If adding yourself or spouse, you may complete



Transfer to my own MCHCP coverage



Divorce (date): __ __ / __ __ / __ __ __ __

Tobacco Attestation)



Transfer to my spouse’s MCHCP coverage



Death (date): __ __ / __ __ / __ __ __ __

Cancel Coverage:

Spouse’s Name



(Last, First, Middle Initial):



Subscriber or

Dependent

Other Coverage:



Medical

Dental

Vision

_______________________________________

___________________________________________

Spouse’s Social Security Number:

Reason:



Other:

__________________________________________

___________________________________________

___ ___ ___ – ___ ___ – ___ ___ ___ ___

Section 3 – Plan Continuation, Enrollment and Coverage Levels

Enroll in a Medical Plan

Enroll in a Dental Plan

Medical

Dental

Vision



UMR PPO 300

UMR HSA Plan*

Delta Dental — Dental Plan

Subscriber Only



UMR PPO 600

Subscriber/Spouse

Enroll in a Vision Plan



Aetna** HSA Plan*

NVA — Premium Vision Plan

Subscriber/Child(ren)



Aetna** PPO 300

NVA — Basic Vision Plan

Subscriber/Family

Medical premiums increase based on each additional child up to five. Refer to the Benefit



Aetna** PPO 600

All medical plan options include

Guide or for details.

prescription drug coverage. The



If enrolling in the HSA Plan, the HSA Acceptance form is also required.

TRICARE Supplement

Medicare Prescription Drug Only Plan

You may enroll in Aetna plans only if you live in the Southwest or South Central Regions.



does not provide medical coverage.

Medicare Prescription Drug Only Plan

Section 4 – Dependents to be Enrolled, Changed or Cancelled

Action – E: Enroll C: Change D: Cancel Relationship – S: Spouse C: Child O: Other (Stepchild, Grandchild, etc.) Coverage – M: Medical D: Dental V: Vision

If proof of eligibility has been previously provided for the dependent, mark the box in the POE column.

Action

Social Security Number

Name

Date of Birth

Relationship

Gender

Coverage

POE

(Last, First, Middle Initial)

(MM/DD/YYYY)

(Circle)

E C D

S C O

M F



__ __ __ – __ __ – __ __ __ __

____________________________________

__ __ / __ __ / __ __ __ __



E C D

S C O

M F

__ __ __ – __ __ – __ __ __ __

____________________________________

__ __ / __ __ / __ __ __ __

If adding a spouse or child, no coverage is provided until proof of eligibility is received. Refer to for details. If more space is needed, please use additional forms.

Section 5 – Spouse Information

If your spouse is an active employee and eligible for insurance coverage through MCHCP, please complete the following information. This helps to ensure you only have to meet one

medical plan family deductible and out-of-pocket maximum. MCHCP reserves the right to request proof of eligibility be provided at any time upon request.

Spouse’s Name

Spouse’s Employer:

Spouse’s Social Security Number:

Spouse’s Date of Birth

(Last, First, Middle Initial):

______________________________________________

__________________________

___ ___ ___ – ___ ___ – ___ ___ ___ ___

__ __ / __ __ / __ __ __ __

Section 6 – Subscriber Authorization

I hereby make the above designation(s) and authorize the deduction necessary to pay for the coverage elected. I also hereby authorize the appropriate providers to release any

documentation necessary to process claims/benefits for myself or my dependent(s). I authorize my chosen plan to provide MCHCP the information necessary to validate benefits

received and payment of claims to which I am entitled under the MCHCP plan.

Signature:

Date

Coverage Effective Date

(MM/DD/YYYY):

______________________________________________________

___ ___ / ___ ___ / ___ ___ ___ ___

Revised: 12/2015