2012 Employer/mco Open Enrollment Form printable pdf download

2012 Employer/mco Open Enrollment Form

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2012 EMPLOYER/MCO OPEN ENROLLMENT FORM

Open Enrollment Period: April 30 – May 25, 2012

INSTRUCTIONS

1. Fully complete the 2012 Employer/MCO Open Enrollment form below

including signature and date. Please type or print clearly. MCO name

and number information has been provided.

2. Fax completed form to CareWorks, toll-free, at 1-888-358-5319. All

forms must be received by CareWorks by 5:00 p.m., May 25, 2012.

3. If you have questions, please call CareWorks toll-free, at 1-888-627-7586.

4. You can enroll directly through BWC by calling 1-800-859-6631. You

will need your BWC Policy # CareWorks’ MCO I.D. Number (10010) to

complete your enrollment.

Policy Number: _________________________________________________________________________

Business Name: _________________________________________________________________________

DBA (if applicable): ______________________________________________________________________

Contact Name: __________________________ __________ ___________________________________

First

Middle

Last

CareWorks

MCO Selected: ______________________

Address:_________________________________________

10010

MCO Number: _______________________

City, State Zip: ____________________________________

Phone: (________) __________-________

County(ies) of operation: ___________________________

Ext._____

Fax: (________) ___________-_________

Number of Employees: _____________________________

/ 2012

Employer Signature:_____________________________________________________________

Date

Title: __________________________________

EMPLOYERS RIGHT TO SELECT

An employer may select any MCO that meets its individual business needs during Open

Enrollment periods. Selection of the MCO is solely the choice of the employer.

2012 Employer/mco Open Enrollment Form