Form Ms-07-422 - Addition/termination Change printable pdf download

Please print neatly using

Addition/Termination Change Form

black or blue ballpoint pen

P. O. Box 7085, Bridgeport CT 06601 • 1-800-444-6222

ALL DATES MUST BE: MM/DD/YYYY

Many transactions can be completed online at the employer area of our website www oxfordhealth com

A. Employer/Employee Information (To be completed by the employer)

Group ID Number:

Group Name:

Employee Insurance ID

Employer Signature

Date

Number:

Employee Name:

B. Transaction

Effective Date

Required Information

Termination

Who:

Employee

Reason:

Left Employer

Discontinue

Spouse/Partner

Discontinue COBRA

NY Young Adult

Dependent(s)

Switched Plans

Other:

NY Young Adult

Who:

Effective Date:

SS#:

Change

Last Name:

Date of Birth:

Middle Intial:

Address changes can be done

First Name:

Other:

Gender:

online or by calling Oxford.

COBRA or

Who :

Reason:

Employee

Left Employer

Date of Event:

State Continuation

Spouse/Partner*

Hours Reduction

Dependent(s)*

Other:

A New Member Enrollment Form is required for: Loss of Dependent Status, Divorce/Separation, or Death of Subscriber.

Transfer

New Plan CSP:

Retiree Drug Subsidy:

Yes

Complete entire section

New Billing Group:

Actively Working:

Yes

Reason:

Enrolled in Medicare Part:

Addition

Who :

Spouse

Reason:

Open Enrollment

Date of Marriage

Civil Union

Loss of Coverage

Date of Civil Union

Complete WHO, REASON

Domestic Partner

Birth/Adoption

Date of Partnership

and SECTION C below

Dependent(s)

Other:

Spouse

Dependent

C. Additional Information

Social Security Number:

Last Name:

First Name, Middle Initial:

Date of Birth: (MM/DD/YYYY)

Gender and Disability Status:

Disabled

Primary Care Physician (PCP) ID Number:

_________________________________

PCP Name: ( If an existing patient, check “Yes”. )

Yes

Actively employed

Full-time Student

Check all that apply:

Not actively employed

(Age 19 - 23)

Prior Carrier

Policy Number:

__________________________________

What coverage you had

Carrier:

__________________________________

prior to this.

From Date:

Thru Date:

D. Coordination of Benefits

Spouse

Dependent

Medicare

Check appropriate

Part A

box and list

Part B

effective date:

Part D

Pharmacy

Policy Number:

___________________________________

Same for all

Carrier:

___________________________________

Effective Date:

Policy Holder:

___________________

BIN:

Group Number:

PCN:

Medical

Policy Number:

___________________________________

Same for all

Carrier:

___________________________________

Policy Holder:

___________________________________

Effective Date:

ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON AN APPLICATION FOR INSURANCE IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES

Employee Signature

Date

MS-07-422

WHITE COPY: INSURER

YELLOW COPY: EMPLOYEE

003 REV 7

Form Ms-07-422 - Addition/termination Change

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