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(Please Print Legibly) GROUP NAME: HEALTH CARRIER: DENTAL ADMINISTRATOR: Stanislaus Foundation For Medical Care VISION Employee Name Last First M.I. Social Security No. Address- Street City State Zip Birthdate Mo Day Yr / / Employer Male Female Single Married Widowed Divorced Separated Department Employee # Hourly Salary Date of Hire Effective Date Mo Day Yr / / Mo Day Yr / / RELATIONSHIP DEPENDENTS COVERED Note if Step-Child’s Name is Different If Dependent has Other Medical Coverage Print Name of Carrier NAME OF EMPLOYER (If Employed) or Name of College or University (If Attending) Medical/Vision Medical/Vision Husband Wife Domestic Partner Last Name First Initial Date of Birth / / / Name of Carrier Name of Carrier Son Daughter Step-Child Last Name First Initial Date of Birth / / / Name of Carrier Name of Carrier Son Daughter Step-Child Last Name First Initial Date of Birth / / / Name of Carrier Name of Carrier Son Daughter Step-Child Last Name First Initial Date of Birth / / / Name of Carrier Name of Carrier Son Daughter Step-Child Last Name First Initial Date of Birth / / / Name of Carrier Name of Carrier Son Daughter Step-Child Last Name First Initial Date of Birth / / / Name of Carrier Name of Carrier IF SON-DAUGHTER IS AGE 19-25, PLEASE COMPLETE (ATTACH ADDITIONAL SHEETS IF NECESSARY) My Son-Daughter is more than 50% dependent on me according to the Internal Revenue Service. Yes No My child was listed as a dependent on my last tax return. Yes No I anticipated claiming my child as a dependent on my next Federal Tax Return. Yes No Is child employed? Yes No If yes, date of hire: / / Hours worked per week: Summer only: Yes No PLEASE NOTE: If spouse is employed, please list spouse’s social security AUTHORIZATION TO OBTAIN OR RELEASE MEDICAL INFORMATION I authorize any physician, health care practitioner, hospital, clinic or other medical or medically-related facility to furnish to Stanislaus Foundation for Medical Care, its agents, or representatives any and all records pertaining to medical history, services rendered, or treatment given to me or anyone now included in this application or who is later included under my coverage for purposed of review, investigation, or evaluation of a claim. I also authorize Stanislaus Foundation for Medical Care, its agents or representatives to disclose to a hospital or health care service plan, self-insurer, or insurer any such medical information obtained if such disclosure is necessary to allow the processing of any claim. This authorization is effective when I sign below and remains in effect as long as Stanislaus Foundation for Medical Care processes Claims for my dependents or me. I understand that I am entitled to a copy of this signed authorization if I request it, and certify by signature that information contained herein is true and correct. I approve the above authorization and make application for membership for my eligible family members and myself. For Office Use Only Signature Date entered initial Date