Medical Plan Selection Form (Page 3 of 3) in pdf

Medical Plan Selection Form Page 3

Step 3:

Please list the members of the family who will be insured on the medical plan.

*Please note: All members on this plan should also be included in the “Application for Health Coverage.”

Relationship to

Name

Date of Birth

Contact

(mm/dd/yyyy)

Self

Spouse/C.U.

partner

Dependent

Step 4:

Please write the month in which you would like coverage to begin.

Month:_____________

(should be at least one full month from application date, if using paper application)

Step 5:

Please tell us how you heard about Vermont Health Connect.

⃝

Employer

⃝

Mail

⃝

Friends/Family

⃝

News

⃝

Internet

⃝

Other: _________________

Step 6:

Read and sign this form.

I understand that I have not provided any financial information to Vermont Health Connect to determine eligibility for

financial assistance. I understand that, by signing this document, I am enrolling in a health care plan and have not

applied for financial help to pay for this plan. I have reviewed the Summary of Benefits and Coverage for my plan and

understand its terms and conditions.

Signature

Date (mm/dd/yyyy)

Mail completed and signed form to:

Vermont Health Connect, 103 South Main Street, Waterbury, VT 05671-8100

205MPS

Page 3 of 3

Medical Plan Selection Form Page 3