Nongroup Enrollment/change Request Form (Page 6 of 7) in pdf

INSTRUCTIONS AND ELIGIBILITY REQUIREMENTS

Instructions

Eligibility

 Except for section [H], you must complete sections A through [J], and sign and date

A. Eligibility requirements are set forth under the Individual Health Coverage Reform

this form, as well as any additional pages you may need to submit with it to provide

Act of 1992, P.L. 1992, c. 161 (N.J.S.A. 17B:27A-2 et seq.).

further requested information.

B. You MUST be a New Jersey resident.

 Please PRINT except when a signature is requested.

C. EXCEPT as F. below applies, you and family members you wish to cover MUST

 If a dependent child is disabled and you want to continue his or her coverage beyond

NOT be eligible to be covered under a: group health plan; a group health benefits

[age 18][the limiting age], describe this in “Other Change” in Section A, and attach

plan; a governmental plan (not including Medicaid); a church plan; or Medicare.

proof of disability.

D. You and any family members you wish to cover are NOT eligible for a standard

 [If a dependent is a full-time post-secondary student, you must attach a current

individual health benefits plan if covered by another individual health benefits plan

course schedule or a letter from the school or its authorized representative

UNLESS you are replacing the other individual health benefits plan by the one for

confirming full-time student status.]

which you are submitting this application.

 You can obtain the providers’ correct names and addresses from the appropriate

E. If you do not specify an effective date in the application, your effective date shall be

provider directory. You may also obtain each provider’s NPI number [from the

no later than the first day of the month following the month in which the completed

provider directory] [or] [and] [at: URL] [or] [and] [by contacting the provider

application was dated and we receive premium payment directly or through our duly

directly.] Providers with multiple office locations and individual providers who

authorized agent UNLESS you submit your application during the October Open

belong to more than one practice or provider entity may have more than one NPI

Enrollment Period (see F. below).

number. You should confirm the correct NPI number for the specific provider and

F. You may apply for coverage for yourself and family members who are covered

office location where you will be seen by contacting that office directly.

under a group health plan, group health benefits plan, a governmental plan, a church

 For provider addresses, include the zip code plus the four digit extension (11 digits)

plan or Medicare during the October Open Enrollment Period IF you wish to replace

 “Previous Coverage” and “Other Health Coverage” includes coverage under a:

the current coverage with a more comprehensive individual health benefits plan.

group health plan resulting from employment, whether with a private or public

The effective date of coverage under the individual health benefits plan in this

(governmental) employer, including such coverage continued through a COBRA

instance will be January 1 of the calendar year following the October Open

election or state continuation provisions; a church plan, Medicare, Medicaid,

Enrollment Period. You SHOULD NOT terminate current coverage until the new

NJFamilyCare, or another individual health benefits plan.

coverage is effective.

 IF YOU HAVE ANY QUESTIONS concerning the benefits and services provided

by or excluded under this [policy], contact a [member services] representative at

[phone number] before signing this form.

 KEEP A COPY OF THIS COMPLETED APPLICATION! [A copy of this

application may be used as a temporary ID card for 30 days from the effective date if

authorized by [Carrier Name]. Coverage must be verified with [Carrier Name] prior

to visiting with a specialist or admission to a hospital.]

CONDITIONS OF ENROLLMENT -- [APPLICANT] ACKNOWLEDGEMENTS AND AGREEMENTS

On behalf of myself and the dependents listed in this Enrollment/Change Request form, I acknowledge that:

I authorize any physician or medical professional, hospital, clinic or other medical care institution, carrier, consumer reporting agency, and any employer to give [Carrier

Name], or any consumer reporting agency acting on behalf of [Carrier Name], information pertaining to employment, other health coverage, and medical advice, treatment

or supplies for any physical or mental condition relevant to me or a minor dependent applying for coverage. I agree that this authorization shall be valid for 30 months from

the date I sign this Enrollment/Change Request form, unless revoked at an earlier date.

I agree that, if I revoke this authorization before it expires, such revocation shall not affect any action that [Carrier Name] has taken in reliance on the authorization.

I understand I may receive a copy of this authorization if I request one.

I agree [Carrier] will provide coverage in accordance with the terms of the contract for the individual [plan] [policy].

I understand that my enrollment and the enrollment of my listed dependents in [Carrier’s Name’s] individual [plan] [policy] is effective upon acceptance by [Carrier’s

Name].

I agree that the provision of coverage and benefits is contingent upon payment of premiums and may be terminated in accordance with the terms of the individual [plan]

[policy] if premiums are not paid timely.

NJ-HINT-Individual

[Internal Carrier Form Number]

Nongroup Enrollment/change Request Form Page 6

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