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1 SDRMA/ CSAC EIA Health Small Group Benefit Election Form Group Name: Effective Date: MEMBER ENROLLMENT OR CHANGE – COMPLETE IN FULL Name (Last, First, MI): Social Security Birth Date (mm/dd/yy): Male Female Home Street Address: (No P.O. Box) City State Zip Home Phone: Work Phone: Mailing Address: (P.O. Box may be used) City State Zip Same as Home Address E-mail Address: Occupation/Title: Date of Hire (mm/dd/yy): Employee Status: Full Time Early Retiree Part Time Medicare Retiree Marital Status: Single Married Domestic Partner Legally Separated Divorced TYPE OF ACTION New Hire Enrollment (list below all dependents to be covered) Annual Open Enrollment Add or Drop Dependent due to Qualifying Event: QE Event: Termination Other: Name/Address Change MEMBER ELECTION Blue Shield Access + HMO 15 EE Only EE + 1 EE + Family Employee PCP Code: Provider Existing Patient: Yes / No Blue Shield Access + HMO 20 EE Only EE + 1 EE + Family Employee PCP Code: Provider Existing Patient: Yes / No Blue Shield EPO EE Only EE + 1 EE + Family Blue Shield Platinum PPO EE Only EE + 1 EE + Family Blue Shield Silver PPO EE Only EE + 1 EE + Family Blue Shield Gold PPO EE Only EE + 1 EE + Family Blue Shield HDHP 10% EE Only EE + 1 EE + Family Blue Shield HDHP 20% EE Only EE + 1 EE + Family HSA (for HDHP Elections Only): Yes No Alpine County Alpine ---PAGE BREAK--- 2 DEPENDENT COVERAGE ADD TERM Name (Last, First, MI): Social Security Birth Date: Male Female Home Street Address: (if different than address above) City,State, Zip Disabled? Yes No Relation: Spouse Domestic Partner Child HMO Provider Name (HMO Plans only): Existing Patient: Yes / No PCP Code: ADD TERM Name (Last, First, MI): Social Security Birth Date: Male Female Home Street Address: (if different than address above) City,State, Zip Disabled? Yes No Relation: Child HMO Provider Name (HMO Plans only): Existing Patient: Yes / No PCP Code: ADD TERM Name (Last, First, MI): Social Security Birth Date: Male Female Home Street Address: (if different than address above) City,State, Zip Disabled? Yes No Relation: Child HMO Provider Name (HMO Plans only): Existing Patient: Yes / No PCP Code: ADD TERM Name (Last, First, MI): Social Security Birth Date: Male Female Home Street Address: (if different than address above) City,State, Zip Disabled? Yes No Relation: Child HMO Provider Name (HMO Plans only): Existing Patient: Yes / No PCP Code: ADD TERM Name (Last, First, MI): Social Security Birth Date: Male Female Home Street Address: (if different than address above) City,State, Zip Disabled? Yes No Relation: Child HMO Provider Name (HMO Plans only): Existing Patient: Yes / No PCP Code: ---PAGE BREAK--- 3 PLEASE READ THE FOLLOWING- AUTHORIZATION REQUIRED I declare that the information given on this form is true and complete to the best of my knowledge and belief. I understand that the information I have provided is the basis on which coverage may be issued under these plans. Any misstatements or omissions may result in future claims being denied and/or my coverage(s) being rescinded. I know that if I do not enroll within 30 days of becoming first eligible (or within 31 days of an IRS‐ qualified change in status) I will have to wait until the next annual enrollment, and may be required to submit evidence of insurability for certain coverage. My signature below certifies that I have applied for the benefits indicated on this form. I understand that my benefit elections may result in deductions from my pay and authorize my employer to make the required deduction. By signing below, I acknowledge all of the terms and provisions as described above. Signature: Date: DECLINATION OF COVERAGE – SIGNATURE REQUIRED- Complete only if declining medical coverage I understand that I am eligible for medical coverage through my employer. I waive the right to enroll in the medical plan as offered by my employer for the following persons (please check all that apply below): Self Spouse Child(ren) Reason for waiver: I have my own other group coverage We are covered through my spouse’s employer My spouse and dependents have other group coverage Signature: Date: I understand and agree by signing this document that I am declining coverage and if I fail to show proof of other group coverage that I will be added to the lowest cost plan automatically. I understand by declining coverage, I will not be eligible for coverage until my employer’s next Open Enrollment period unless I qualify for coverage due to a HIPAA qualifying event (including getting married, having a child, or involuntarily losing my other coverage). If a HIPPA qualifying event occurs and I want to enroll in other group coverage I know that I must submit proof of other group coverage or my request will not be processed.