Oregon Continuation Election Form - Providence Health Plan

Oregon Continuation

______________________

Date form distributed

Election Form

______________________

Effective date

For Employer Groups with 19 or fewer employees,

______________________

Date election period expires

or Employer Groups not subject to COBRA

If you wish to apply for Oregon continuation coverage, you must complete all sections of this form and return it to your employer

within 10 days of the qualifying event or 10 days of receiving your notice of continuation coverage, whichever is later.

SECTION 1

QUALIFYING INDIVIDUAL INFORMATION

LAST NAME

FIRST NAME

M.I.

SOCIAL SECURITY NUMBER

DAYTIME PHONE

ADDRESS (STREET, CITY, STATE, ZIP CODE)

MEMBER ID NO.

GROUP NO.

DATE OF BIRTH

GENDER

MARITAL STATUS

MALE

FEMALE

SINGLE

MARRIED

DIVORCED

SEPARATED

WIDOWED

SECTION 2

QUALIFYING EVENT INFORMATION

I am eligible for continuation of medical coverage due to:

Termination of employment. Employment termination date: ________________________

Reduction in work hours. Reduction effective date: _____________________

Covered employee becoming eligible for Medicare. Medicare eligibility effective date: _____________________

Divorce or legal separation from a covered employee. Divorce or legal separation date: _____________________

Death of a covered employee. Date of death: _____________________

Termination of membership in group health plan. Membership termination date: _____________________

Covered dependent child no longer meets eligibility requirements. Loss of eligibility effective date: ____________________

Is anyone applying for continuation covered by another group insurance?

Yes

No

If yes, name of insured: __________________________

Insurance carrier: _____________________________

If you are not the covered employee, give the name and member ID number of the employee who is

primary on the policy:

Name: __________________________________

Member ID No.: _____________________________

SECTION 3

Please list all dependent family members continuing coverage.

Last Name

First Name

Middle Initial

Date of Birth

Gender

Relationship

SECTION 4

SIGNATURE OF QUALIFYING INDIVIDUAL

Accuracy of information: Any person who, with an intent to knowingly defraud, files this election form with the materially false information or conceals material

information, may be subject to criminal and civil penalties and Providence Health Plan may cancel such person’s membership and refuse to pay claims.

Subscriber Acknowledgement: I acknowledge and understand that Providence health Plan may request or disclose health information, other than psychotherapy

notes, about me or my dependents (persons who are listed for benefits coverage on this state continuation election form) for the purpose of: (a) performing the health

plan business operation s of Providence Health Plan; (b) facilitating health care treatment; (c) issuing or facilitating payment for health care services; or (d) as required

by law. The use or disclosure of psychotherapy notes by Providence Health Plan is restricted to circumstances in which the patient has provided a signed authorization.

For more information about such uses and disclosures, including uses and disclosures required by law, please refer to the Notice of Privacy Practices. A copy is available

at or by calling customer service.

SIGNATURE: _________________________________________________________

DATE: ________________________________

OR 0212 STATECONTFORM

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