Hint Group Enrollment - Group Enrollment/change Request Form (Page 6 of 7) in pdf

INSTRUCTIONS

[Employers] – You must complete the [Employer] Group Information and sections A and [L] in order for this

Qualifying Events

application to be processed.

COBRA and NJSGC

C1. Termination of job or reduction in hours

[Employees] – You must complete sections B through [J] and submit the signature of each Over-Age Child

C2. Employee enrollment in Medicare (COBRA only)

for which a Dependent Under 30 Continuation Election is made in accordance with Section [K] in order for

C3. Divorce (COBRA/NJSGC); civil union dissolution (NJSGC)

this application to be processed.

C4. Death of employee

C5. Loss of dependent child status under the plan

Please PRINT except when a signature is requested.

C6. Disability (occurring subsequent to another qualifying event)

If a dependent is disabled and you want to continue his or her coverage beyond [age 18][the limiting age],

you do not have to make a COBRA/NJSGC or Dependent Under 30 election. Instead, select “Other” in

Dependent Under 30

D1. Loss of dependent status and otherwise eligible

Section A3, and attach proof of disability.

D2. Reestablish eligibility: residency

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

D3. Reestablish eligibility: nonresident full-time student

[If a dependent is a full-time post-secondary student, you must attach a current course schedule or a letter

D4. Reestablish eligibility: change in marital status

from the school or its authorized representative confirming full-time student status.]

D5. Reestablish eligibility: change in parental status

You can obtain the providers’ correct names and addresses from the appropriate provider directory. You

D6. Reestablish eligibility: termination of other coverage

may also obtain each provider’s NPI number [from the provider directory] [or] [and] [at: URL] [or] [and]

[by contacting the provider directly.] Providers with multiple office locations and individual providers

who belong to more than one practice or provider entity may have more than one NPI number. You

should confirm the correct NPI number for the specific provider and office location where you will be

seen by contacting that office directly.

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 group [plan] [policy].

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 group [plan]

[policy] if premiums are not paid timely. I authorize my Employer to withhold payments from my wages as contribution to the premium, as appropriate.

Carrier instructions

(not to be included in the Enrollment/Change Request form when printed by the carrier)

Carrier should insert its logo and name where indicated, or leave the table blank, or blacked-out.

Carrier must replace bracketed text “carrier name” with carrier’s full name throughout the document.

If the carrier refers to the “Employer” using another term such as “Planholder” or “Contractholder” or some similar term, replace the term “Employer” with such other

term throughout the document.

If the carrier refers to “Group Number/Class Code” using some other term such as “Policy Number,” “Control Number” or some similar term, replace the term “Group

Number/Class Code” with such other term.

Replace “on back” with appropriate directions if the instructions are not provided on the reverse side.

If the carrier refers to the “Enrollee/Subscriber” using another term such as “Member” or “Applicant” or some similar term, replace the term “Enrollee/Subscriber” with

such other term throughout the document.

NJ-HINT-Group

[Internal Carrier Form Number]

Hint Group Enrollment - Group Enrollment/change Request Form Page 6

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