Enrollment Change Form - Connecticare
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1
2Enrollment/Change Form
, Inc. & Affiliates
P.O. Box 4058, Farmington, CT 06034-4058
1-800-251-7722
Please print clearly, complete in full using ballpoint pen.
EMPLOYEE: Complete the following two sections, sign at bottom and read information on reverse side.
Please check appropriate item: □ New Enrollment □ Terminate Enrollment
□ Add Dependent
□ Remove Dependent
□ Change Provider
□ Change Division
□ COBRA Election
□ Other (Name change, address change, etc. Indicate reason for change.)
Plan type:
□ HMO
□ High Deductible Health Plan (HDHP)
□ Point-of-Service (POS)
□ PPO
□ FlexPOS
□ Other
Plan Name: (from Benefit Summary)
ConnectiCare, Inc. = HMO, HDHP, POS Benefit Plans and ConnectiCare Insurance Company, Inc. = PPO and FlexPOS Benefit Plans. MA employers cannot purchase CCI or CICI products.
□ Widowed
□ Divorced
Marital Status: □ Single
□ Married/Civil Union
□ Domestic Partner
□ Legally Separated
□ Separated
First Name
Middle Name
Last Name
Street Address
City
State
ZIP Code
Home Telephone Number
Work Telephone Number
E-mail Address
Primary Language (optional)
MEMBER(S):
Date of Birth
ConnectiCare
Existing
First Name/Middle Initial/Last Name
Social Security Number (required)
Sex
(mm/dd/yy)
Primary Care Provider
Provider ID Number (optional) Patient
Employee
□ M
□ Yes
□ F
□ No
Spouse/Civil Union/Domestic Partner
□ M
□ Yes
□ F
□ No
Dependent 1
□ Yes
□ M
□ F
□ No
Dependent 2
□ Yes
□ M
□ No
□ F
Dependent 3
□ Yes
□ M
□ No
□ F
Are you currently using tobacco?
Employee □ Yes □ No
Spouse/Civil Union/Dom. Partner □ Yes □ No
Dependent 1 □ Yes □ No
Dependent 2 □ Yes □ No
Dependent 3 □ Yes □ No
Race/Ethnicity (optional):
This information is designed for the purpose of data collection and will not be used to determine eligibility, rating or claim payment.
Employee:
□ White □ Black/African American □ Hispanic/Latino □ Asian □ Amer. Indian/Alaska Native
□ Native Hawaiian/Pacific Islander □ Other
□ Unknown
Spouse/Civil Union/Domestic Partner:
□ White □ Black/African American □ Hispanic/Latino □ Asian □ Amer. Indian/Alaska Native
□ Native Hawaiian/Pacific Islander □ Other
□ Unknown
Dependent 1:
□ White □ Black/African American □ Hispanic/Latino □ Asian □ Amer. Indian/Alaska Native
□ Native Hawaiian/Pacific Islander □ Other
□ Unknown
Dependent 2:
□ White □ Black/African American □ Hispanic/Latino □ Asian □ Amer. Indian/Alaska Native
□ Native Hawaiian/Pacific Islander □ Other
□ Unknown
Dependent 3:
□ White □ Black/African American □ Hispanic/Latino □ Asian □ Amer. Indian/Alaska Native
□ Native Hawaiian/Pacific Islander □ Other
□ Unknown
□ Check if enrolling a disabled dependent age 26 or over and contact ConnectiCare to obtain a form for submitting proof of disability.
Other health care coverage:
Will you have other health insurance in addition to this ConnectiCare plan, under a Group, HMO or Medicare plan?
□ Yes
□ No
If yes, name of person covered
Employer
Insurance Co. Name and Address
Policy Number
Medicare (Please attach a copy of your Medicare card.)
(Please attach a copy of your group medical insurance card.)
□ Part A
□ Part B
□ Retired
EMPLOYER: Complete this section. Form cannot be processed without this information.
COBRA □ Yes Length of coverage:
Date of Hire
Hours per week Coverage Effective Date
Coverage End Date
(mm/dd/yy)
(mm/dd/yy)
(mm/dd/yy)
/
/
/
/
/
/
□ No
□ 30 months □ 36 months □ Other
Employee Work Location
Group Name
Plan Name
Group Number/Division
Employer Signature
Title
Date
�
Important: By signing here you are indicating that you have read and understand the information on the front and back of this form. This authorization is valid as long as you are
enrolled in a ConnectiCare health plan, and for one year after enrollment in the plan ends. I certify that the information supplied in the form is correct. I agree to the consent on
the reverse side of this form.
�
Employee’s Signature
Date
FOO1 07/14
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