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Fillable Printable UnitedHealthcare Application Form

Fillable Printable UnitedHealthcare Application Form

UnitedHealthcare Application Form

UnitedHealthcare Application Form

Page 1of 4
SG.EE.14.DC 5/13
425-6213 8/13
[groups of2-50]
T
o speedthe enrollmentprocess, pleasebe thoroughand fillout allsections thatapply.
G
roup Name
Requested EffectiveDate ofCoverage/Date ofChange
//
Group NamePolicy Number
D
ate ofHire
//
Position/Title
Hours Workedper week
Salary$_____________
Required onlyif Life,STD,
or LTDPlan basedon salary
If youare waivingall coverage,please completesections Aand F.
Last NameFirst NameMISocial SecurityNumber
AddressApt #CityStateZip CodeHome/CellPhone
Date ofBirthGenderEmail AddressWork Phone
//
M
F
Marital Status
Single
Married
Divorced
Widowed
Language Preference, if not English
Primary Care Physician
2
Existing Patient?
Yes
NoPrimary Care Dentist
3
Physician First & Last Name _________________________________Dentist First & Last Name __________________________________
Address _________________________________________________ID# ___________________________________________________
ID# ___I___I___I___I___I___I___I___I___I___I___I I___I___IExisting Patient?
Yes
No
List All Enrolling (Attach sheet if necessary)
Relationship
4
Last NameFirst NameMISex Date of Birth
M
F
/ /
Social Security Number
Primary Care Physician
2
Existing Patient?
Yes
NoPrimary Care Dentist
3
Physician First & Last Name _________________________________Dentist First & Last Name __________________________________
Address _________________________________________________ID# ___________________________________________________
ID# ___I___I___I___I___I___I___I___I___I___I___I I___I___IExisting Patient?
Yes
No
(1) Tobacco means all tobacco products, including, but not limited to, cigarettes, cigars, and chewing tobacco. You should only check the “yes” box above if
tobacco was used four or more times per week on average (excluding religious or ceremonial use) within the past 6 months by someone of legal age to
purchase tobacco in the state of residence. (2) For UnitedHealthcare Compass, Navigate, Select, Select Plus, and other products requiring you to choose a
Primary Care Physician (PCP), you must use the UnitedHealthcare directory of providers to choose a PCP for yourself and each of your covered dependents.
(3) Please see employer representative as some dental plans require a Primary Care Dentist (PCD) selection. (4) For court ordered dependent, legal
documentation must be attached. If a dependent does not reside with eligible employee, please provide address on a separate sheet. (5) If you answered “Yes”
for Disabled and the dependent child is 26 years of age or older, unmarried, chiefly dependent upon subscriber for support and is not able to be self-
supporting because of a physically or mentally disabling injury, illness or condition, please attach a medical certification of disability.
To Be Completed by Employer
Reason for Application
New Group Plan
New Hire
Life Event/Date_______
Annual
Status Change_______Open
Dependent Add/DeleteEnrollment
Change Name/Address
Late
Part time to Full timeEnrollee
Waiving Coverage
Termination
Other_________________________
Employee Type
(Check all that apply)
Active
COBRA
State Continuation
Start dt ____/____/____
End dt____/____/____
Hourly
Salary
Union
Non-Union
Retired
Other ____________________________
A. Employee Information
B. Family Information
Employee Enrollment Form
Coverage Provided by “UnitedHealthcare and Affiliates”:
Medical coverage provided by UnitedHealthcare Insurance Company, UnitedHealthcare of the Mid-Atlantic,Inc. or Optimum Choice, Inc.
Dental coverage provided by UnitedHealthcare Insurance Company
Life, Short-Term Disability (STD), Long-Term Disability (LTD) Insurance coverage provided by UnitedHealthcare Insurance Company
Vision coverage provided by UnitedHealthcare Insurance Company
(DO NOT STAPLE)
Do you use tobacco?
1
Yes No
If yes, are you currently participating in a tobacco cessation program or
do you intend to join one?
Yes
No
Do you use tobacco?
1
Yes No
If yes, are you currently participating in a tobacco cessation program or
do you intend to join one?
Yes
No
Spouse
/Domestic
Partner
UnitedHealthcare Insurance Company
Optimum Choice, Inc.
UnitedHealthcare of the Mid-Atlantic, Inc.
Page 2of 4
Employee Name __________________________________________________________________________________________________________
L
ist All Enrolling (Attach sheet if necessary)
Relationship
4
Last NameFirst NameMISex Date of Birth
M
F
/ /
Social Security Number
Dependent
Primary Care Physician
2
Existing Patient?
Yes
NoPrimary Care Dentist
3
Existing Patient?
Yes
No
Physician First & Last Name _________________________________Dentist First & Last Name __________________________________
Address _________________________________________________ID# ___________________________________________________
ID# ___I___I___I___I___I___I___I___I___I___I___I I___I___I
Permanently disabled and age 26 or older
5
Yes No
Relationship
4
Last NameFirst NameMISex Date of Birth
M
F
/ /
Social Security Number
Dependent
Primary Care Physician
2
Existing Patient?
Yes
NoPrimary Care Dentist
3
Existing Patient?
Yes
No
Physician First & Last Name _________________________________Dentist First & Last Name __________________________________
Address _________________________________________________ID# ___________________________________________________
ID# ___I___I___I___I___I___I___I___I___I___I___I I___I___I
Permanently disabled and age 26 or older
5
Yes No
Relationship
4
Last NameFirst NameMISex Date of Birth
M
F
/ /
Social Security Number
Dependent
Primary Care Physician
2
Existing Patient?
Yes
NoPrimary Care Dentist
3
Existing Patient?
Yes
No
Physician First & Last Name _________________________________Dentist First & Last Name __________________________________
Address _________________________________________________ID# ___________________________________________________
ID# ___I___I___I___I___I___I___I___I___I___I___I I___I___I
Permanently disabled and age 26 or older
5
Yes No
Relationship
4
Last NameFirst NameMISex Date of Birth
M
F
/ /
Social Security Number
Dependent
Primary Care Physician
2
Existing Patient?
Yes
NoPrimary Care Dentist
3
Existing Patient?
Yes
No
Physician First & Last Name _________________________________Dentist First & Last Name __________________________________
Address _________________________________________________ID# ___________________________________________________
ID# ___I___I___I___I___I___I___I___I___I___I___I I___I___I
Permanently disabled and age 26 or older
5
Yes No
B. Family/Dependent Information (continued)
Do youuse tobacco?
1
Yes
No
If yes, are you currently participating
in a tobacco cessationprogram ordo you intendto join one?
Yes
No
Please check the box for each coverage in which you or your dependents are enrolling.
If your employer offers a choice of plans, indicate which plan you are selecting. Indicate the dollar amount
selected for the Life and Accidental Death & Dismemberment (AD&D), Supplemental Life, Short-Term Disability
(STD), and Long-Term Disability (LTD) plans. Benefit offerings are dependent upon employer selection.
PersonMedicalDentalVisionBasic Life/AD&DSupp Life/AD&D
Employee
_____________
_____________
$_____________
$_____________
Spouse [Domestic Partner]
_____________
_____________
$_____________
$_____________
Dependent
_____________
_____________
$_____________
$_____________
PersonSTDLTD
Employee
Life Insurance Beneficiary Full Name and Address
(if applying for Life Insurance with UnitedHealthcare)
Relationship
Primary
Secondary
C. Product Selection
Do youuse tobacco?
1
Yes
No
If yes, are you currently participating
in a tobacco cessationprogram ordo you intendto join one?
Yes
No
Do youuse tobacco?
1
Yes
No
If yes, are you currently participating
in a tobacco cessationprogram ordo you intendto join one?
Yes
No
Do youuse tobacco?
1
Yes
No
If yes, are you currently participating
in a tobacco cessationprogram ordo you intendto join one?
Yes
No
W
ithin the last 12 months, have you, your spouse, or your dependents had any other medical coverage?
NO
YES (if yes, please complete this section.)
Prior medical carrier name ____________________________________________________ Effective date
___/___/___ End date ___/___/___
Prior coverage type:
Employee
Spouse
Child(ren)
Family
D. Prior Medical Insurance Information
Medicare – Employee Information:If enrolled in Medicare, please attach a copy of your Medicare ID card.
Enrolled in Part A: Effective Date _____________
Ineligible for Part A*
Not Enrolled in Part A (chose not to enroll)**
Enrolled in Part B: Effective Date _____________
Ineligible for Part B*
Not Enrolled in Part B (chose not to enroll)**
Enrolled in Part D: Effective Date _____________
Ineligible for Part D*
Not Enrolled in Part D (chose not to enroll)**
Reason for Medicare eligibility:
Over 65
Kidney Disease
Disabled
Disabled but actively at work
Are you receiving Social Security Disability Insurance (SSDI)?
YES
NO Start Date ___ /___ /___
Medicare – Spouse/Dependent Name: ____________________________________________
Enrolled in Part A: Effective Date _____________
Ineligible for Part A*
Not Enrolled in Part A (chose not to enroll)**
Enrolled in Part B: Effective Date _____________
Ineligible for Part B*
Not Enrolled in Part B (chose not to enroll)**
Enrolled in Part D: Effective Date _____________
Ineligible for Part D*
Not Enrolled in Part D (chose not to enroll)**
Reason for Medicare eligibility:
Over 65
Kidney Disease
Disabled
Disabled but actively at work
*Only check “Ineligible” if you have received documentation from your Social Security benefits that indicate that you are not eligible for Medicare.
** If you are eligible for Medicare on a primary basis (Medicare pays before benefits under the group policy), you should enroll in and maintain
coverage under Medicare Part A, Part B, and/or Part D as applicable.
O
n the day this coverage begins, will you, your spouse or any of your dependents be covered under any other medical health plan or policy,
including another UnitedHealthcare plan or Medicare?
YES (continue completing this section)
NO (skip the rest of this section)
Name of other carrier ______________________________________________________
Other Group Medical Coverage InformationTypeEffective DateEnd DateName and date of birth of policyholder
(only list those covered by other plan)(B/S/F)*MM/DD/YYMM/DD/YYfor other coverage
Employee:
Spouse Name:
Dependent Name:
Dependent Name:
Dependent Name:
*B.Enter ‘B’ when this dependent is covered under both you and your spouse’s insurance plan (married)
S.Enter ‘S’ if you are the parent awarded custody of this dependent and no other individual is required to pay for this dependent’s medical expenses.
F.Enter ‘F’ if this dependent is covered by another individual (not a member of your household) required to pay for this dependent’s medical expenses.
E. Other Medical Coverage Information
This section must be completed. (Attach sheet if necessary.)
Page 3of 4
Employee Name __________________________________________________________________________________________________________
F. Waiver of Coverage
I decline all coverage for:
Myself
Spouse
Dependent Children
Myself and all dependents
Declining coverage due to existence of other coverage:
Spouse’s Employer’s Plan
Individual Plan
Covered by Medicare
Medicaid
COBRA from Prior Employer
VA Eligibility
Tri-Care
I (we) have no other coverage at this time
Other ____________________________________
I understand that by waiving coverage at this time, I
will not be allowed to participate unless I qualify at a
special enrollment period or as a late enrollee, if
applicable, or at the next open enrollment period.
DateEmployee Signature if waiving coverage
Page 4 of 4
1. Race, check all that apply:
White
Black, African-American
American Indian/Alaska Native
Asian
Native Hawaiian/Pacific Islander
Other Race, please specify_______________________
2. Are you of Hispanic or Latino origin?
Yes
No
NOTE: Responding to this question is optional and is not required. Data collected in this section will be used only to help communicate with
enrollees and inform them of specific programs to enhance their well-being. This information will not be used in the eligibility process.
H. Census Information (optional)
G
. Signature
DateEmployee Signature for all applying Spouse Signature (if applying for coverage)
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an
application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
I
authorize UnitedHealthcare Insurance Company and its affiliates (collectively, "UnitedHealthcare") to obtain, use and disclose my medical,
claim or benefit records, including any individually identifiable health information contained in these records. I understand these records may
contain information created by other persons or entities (including health care providers) as well as information regarding the use of drug,
alcohol, HIV/AIDS, mental health (other than psychotherapy notes), sexually transmitted disease and reproductive health services. I authorize
any health care provider, pharmacy benefit manager, other insurer or reinsurer, hospital, clinic or other medical facility, health care
clearinghouse, and any of their affiliates, representatives or business associates, to disclose my information to UnitedHealthcare and Affiliates.
I understand that the purpose of the disclosure and use of my information is to allow UnitedHealthcare to facilitate the appropriate
management of treatment, services, payment and benefits. I further understand that the information disclosed will not be used for purposes
of eligibility, enrollment, underwriting and premium risk rating. I understand this authorization is voluntary and I may refuse to sign the
authorization. I understand I may revoke this authorization at any time by notifying my UnitedHealthcare representative in writing, except to
the extent that action has already been taken in reliance on this authorization. As required by HIPAA, UnitedHealthcare also requires that I
acknowledge the following, which I do: I understand that information I authorize a person or entity to obtain and use may be re-disclosed and
no longer protected by federal privacy regulations. This authorization, unless revoked earlier, expires 30 months after the date it is signed.
I understand that I am completing a joint life and health application and that each response must be complete and accurate. I (we) request the
indicated group medical coverage. I authorize any required premium contributions to be deducted from my earnings. I (we) have not given the
agent or any other persons any required information not included on the application. I (we) understand that UnitedHealthcare is not bound by
any statements I (we) have made to any agent or to any other persons, if those statements are not written or printed on this application and
any attachments.
Please note that if you leave out information or make a misrepresentation on this form we may be allowed by law to take one or more of the
following actions: terminate or non-renew your coverage or change your premium retroactively to the date your policy became effective.
Please maintain a copy of this authorization for your records.
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