Full Text
SDRMA / CSAC-EIA Health Small Group Member Enrollment Form Group County: New Enrollment Add Dependent; Qualifying Event ; Qualifying Event Date Change Address/Name COBRA; Qualifying Event ; Qualifying Event Date Delete Dependent Termination Open Enrollment Other SELECTED COVERAGE : Select one (grey sections not offered by your employer.) Access + HMO 15 EE only EE + 1 EE + Family Silver PPO EE only EE + 1 EE + Family Access + HMO 20 EE only EE + 1 EE + Family Gold PPO EE only EE + 1 EE + Family EPO EE only EE + 1 EE + Family HDHP 10% with HSA EE only EE + 1 EE + Family Platinum PPO EE only EE + 1 EE + Family HDHP 20% with HSA EE only EE + 1 EE + Family Other: Mid Year Plan Changes Only (Note: This section does not apply to open enrollment): I wish to ADD coverage for (check all that apply): Employee only Spouse/RDP only Child(ren) only I wish to DELETE coverage for (check all that apply): Employee only Spouse/RDP only Child(ren) only EMPLOYEE INFORMATION Last Name First Name M.I. Male Female Social Security Number Birth Date (mm/dd/yyyy) Home Phone: Work Phone: Residence Street Address (No P.O. Box) City State Zip Code Mailing Street Address City State Zip Code Occupation/Title: Department: Date of Hire (mm/dd/yyyy) Hours Worked Per Pay Period Employee Status: FT PT Early Retiree Medicare Retiree Marital Status: Single Married Registered Domestic Partner (RDP) Legally Separated Divorced Medical Group (IPA/MG) # (HMO Only) Physician Name (First, Last) (HMO Only) Primary Care Physician (PCP) # (HMO Only) Is this your current M.D.? (HMO Only) Yes No Medicare: Part A Part B Medicare Claim / HICN # E-Mail Address: Effective Date: Alpine County has the Platinum Plan only ---PAGE BREAK--- DEPENDENT INFORMATION (Please list all eligible family members to be enrolled. Attach additional sheets if necessary.) Spouse RDP Last Name First Name M.I. Male Female Social Security Number Birth Date (mm/dd/yyyy) Medicare Part A Part B Medicare Claim / HICN # Residence Street Address (No P.O. Box) Check here if same as employee City State Zip Code Medical Group (IPA/MG) # (HMO Only) Physician Name (First, Last) (HMO Only) Primary Care Physician (PCP) # (HMO Only) Is this your current M.D.? (HMO Only) Yes No Son Daughter Last Name First Name M.I. Social Security Number Birth Date (mm/dd/yyyy) Overage Dependent Type Disabled Under age 26 Medicare Part A Part B Medicare Claim / HICN # Residence Street Address (No P.O. Box) Check here if same as employee City State Zip Code Medical Group (IPA/MG) # (HMO Only) Physician Name (First, Last) (HMO Only) Primary Care Physician (PCP) # (HMO Only) Is this your current M.D.? (HMO Only) Yes No Son Daughter Last Name First Name M.I. Social Security Number Birth Date (mm/dd/yyyy) Overage Dependent Type Disabled Under age 26 Medicare Part A Part B Medicare Claim / HICN # Residence Street Address (No P.O. Box) Check here if same as employee City State Zip Code Medical Group (IPA/MG) # (HMO Only) Physician Name (First, Last) (HMO Only) Primary Care Physician (PCP) # (HMO Only) Is this your current M.D.? (HMO Only) Yes No Son Daughter Last Name First Name M.I. Social Security Number Birth Date (mm/dd/yyyy) Overage Dependent Type Disabled Under age 26 Medicare Part A Part B Medicare Claim / HICN # Residence Street Address (No P.O. Box) Check here if same as employee City State Zip Code Medical Group (IPA/MG) # (HMO Only) Physician Name (First, Last) (HMO Only) Primary Care Physician (PCP) # (HMO Only) Is this your current M.D.? (HMO Only) Yes No ---PAGE BREAK--- DECLINATION OF COVERAGE (Complete this section if any coverage is to be declined by you are your eligible dependents.) I decline Medical coverage for: Self Spouse/RDP Only Other Coverage Child(ren) Only Spouse/RDP and Child(ren) Only Insurance Carrier Name ; or The Following Dependents Only Other reasons STOP AND READ CAREFULLY. SIGN ONLY IF DECLINING COVERAGE. IF SIGNED IN ERROR, PLEASE CROSS OUT AND INITIAL. The available coverages have been explained to me by my employer. I have been given the chance to apply for the available coverages. I have decided not to enroll myself and/or my dependent(s). By declining coverage I acknowledge that my dependents and I may have to wait to be enrolled until the next Open Enrollment period or qualifying event. Additionally, by signing below I certify that the reason I am declining coverage is accurate as indicated by the check marks above. Employee Signature Date ACCEPTANCE OF COVERAGE (Signature required.) Authorization to obtain or release medical information explanation: The Authorization below to obtain and release medical information is being requested of you to comply with the terms of the Confidentiality of Medical Information Act, effective January 1, 1980, Section 56 et.Seq. of the California Civil Code. Your cooperation is being requested. Authorization to obtain or release medical information: I hereby authorize my physician, health care practitioners, hospital, clinic or other medically related facility to furnish to my medical insurance provider, its representatives or designees, any and all records pertaining to medical history, service rendered or treatment given to anyone under the policy for the purpose of review, investigation, or evaluation of an application, claim, appeal, (including the release to an independent review organization) or grievance, or for preventive health or health management purposes. I authorize my health insurance provider, its representatives or designees to disclose to a hospital or health care service plan, self insurer any such medical information obtained if disclosure is necessary to allow the processing of any claim. I attest by signing below that I have reviewed the information provided on this application and to the best of my knowledge and belief, it is true and accurate with no omissions or misstatements. DEDUCTION AUTHORIZATION: If applicable, I authorize my employer to deduct from my wages the required dues. NON-PARTICIPATING PROVIDER: I understand that I am responsible for a greater portion of my medical costs when I use a non- participating provider. HIV TESTING PROHIBITED: California law prohibits HIV tests from being required or used by health insurance companies as a condition of obtaining health insurance. EFFECTIVE DATE: The effective date of coverage is subject to Blue Shield of California and/or the California State Association of Counties Excess Insurance Authority approval. REQUIREMENT FOR BINDING ARBITRATION The following provision does not apply to class actions: IF YOU ARE APPLYING FOR COVERAGE, PLEASE NOTE THAT THE SPECIAL DISTRICT RISK MANAGEMENT AUTHROITY, BLUE SHIELD OF CALIFORNIA REQUIRE BINDING ARBITRATION TO SETTLE ALL DISPUTES INCLUDING BUT NOT LIMITED TO DISPUTES RELATING TO THE DELIVERY OF SERVICE UNDER THE PLAN/POLICY OR ANY OTHER ISSUES RELATED TO THE PLAN/POLICY AND CLAIMS OF MEDICAL MALPRACTICE, IF THE AMOUNT IN DISPUTE EXCEEDS THE JURISDICTIONAL LIMIT OF SMALL CLAIMS COURT. It is understood that any dispute including disputes relating to the delivery of services under the plan/policy or any other issues related to the plan/policy, including any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration. THIS MEANS THAT YOU AND BLUE OF CALIFORNIA ARE WAIVING THE RIGHT TO A JURY TRIAL FOR BOTH MEDICAL MALPRACTICE CLAIMS, AND ANY OTHER DISPUTES INCLUDING DISPUTES RELATING TO THE DELIVERY OF SERVICE UNDER THE PLAN/POLICY OR ANY OTHER ISSUES RELATED TO THE PLAN/POLICY. Please sign and date this application: Employee Signature Signature of witness (only required if employee signature is Date SIGN