Coventry Employee Enrollment/change Form printable pdf download

Pennsylvania in-area PPO is underwritten by HealthAssurance Pennsylvania, Inc., d.b.a Coventry HealthAmerica (“HealthAmerica”). Pennsylvania Out-of-

area PPO products are underwritten by Coventry Health and Life Insurance Company, d.b.a. Coventry HealthAmerica (“HealthAmerica”).

Employee Enrollment/Change Form

Important: Please print clearly in BLACK ink or type as instructed in each section. Initial and date corrections; correction fluid is not permitted. Read and

sign the Acknowledgements Section.

Product Choice

Choose one (1) product only.

Platinum

Gold

Silver

Bronze

OTHER

None/ Waive

 _________

 _______

 _________



Employer Information

Company Name:

Group Number:

Date Employed

Effective Date of

Full-Time :

___ / ___ / _______ (mm/dd/yyyy)

Coverage:

___ / ___ / _______ (mm/dd/yyyy)

Reason For Enrollment:

Employee Status: Active Employee

 New Group  COBRA

 State Continuation  New Hire

COBRA

 Retired

 Qualifying Event

 Open Enrollment

 State Continuation

Date: ___ / ___ / _______ (mm/dd/yyyy)

Other__________________

Reason For Change

Effective Date of

(Please check all that apply and include supporting documentation)

Change:

___ / ___ / _______ (mm/dd/yyyy)

 Enroll Dependent Terminate Dependent Terminate Subscriber

 Name Change (previous name)  Address/Phone

 PCP Change __________________(New PCP Name)

Termination Reason:

 Group Request

Member Request

Deceased

Subscriber Information

Please provide information on the Subscriber.

Last Name

First Name

County

Home Address (not P.O. Box)

City

State

Zip

Phone Number(s):

 Home (

)

 Work (

)

Mailing Address (If different from address above)

City

State

Zip

 Mobile (

)

 If available, I would like to get

information by Text.

Marital Status

Job Description

Hours worked: ____________/week

 Single/Widow

Married

Divorced

E-mail Address

Primary Language (if other than English):

 Spanish (Español)  Navajo (Dine)

 Chinese (中文)

 Tagalog (Tagalog)

ELECTRONIC COMMUNICATIONS: I ACKNOWLEDGE AND UNDERSTAND THAT BENEFIT DOCUMENTS, LEGAL DOCUMENT, AND PROVIDER NETWORK INFORMATION

FOR HEALTHAMERICA PLANS WILL BE MADE AVAILABLE TO ME IN ELECTRONIC FORMAT THROUGH THE HEALTHAMERICA WEBSITE AND MY ONLINE SERVICES AT

MY ENROLLMENT IN THE PLAN INCLUDES THIS ELECTRONIC ACCESS. TO RECEIVE PRINTED DOCUMENTS AT NO COST TO ME, I MUST

CONTACT CUSTOMER SERVICE TOLL-FREE AT1-800-788-8445 IN CENTRAL AND EASTERN PA OR 1-800-735-4404 IN WESTERN PA.

HAPA- HASPA/CHL-ENRLL2016

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Coventry Employee Enrollment/change Form

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