Fillable 2019-20 MCW Student Insurance Enrollment Form (Medical College of Wisconsin)

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2019-20 MCW Student Insurance Enrollment Form (Medical College of Wisconsin)

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The 2019-20 MCW Student Insurance Enrollment Form (Medical College of Wisconsin) form is 8 pages long and contains:

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  • 16 check-boxes
  • 147 other fields

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MCW STUDENT INSURANCE
1 of 8
2019-20 MCW Student Insurance Enrollment Form
Please complete all sections of this enrollment form unless stated otherwise in the beginning of any section. Once
completed, please upload this form per instructions received from your school.
Medical / Pharmacy / MSA Students
If you have any questions, please visit Sarah Jean Kaehny in the Office of Student Health & Wellness, email
student_health@mcw.edu, or call (414) 955-4219.
Graduate / MSTP Students
If you have any questions, please contact Diane VerHaagh by emailing dverhaagh@mcw.edu or call (414) 955-8090.
More information can be found in the enrollment guide.
When entering information such as date of birth and phone number, please do not include any dashes, slashes
or spaces. Use only numbers.
What student classification group do you belong to?
SECTION 1: STUDENT INFORMATION
Last Name First Name M.I.
Social Security Number (9 digits, no dashes) Date of Birth (MMDDYYYY) Phone Number with Area Code
(no dashes or spaces)
Street Address Apt / Suite / P.O. Box Number
City State ZIP Code Email Address
Sex: Male Female
MCW Start Date (MMDDYYYY)
Are you disabled / unable to perform normal school activities? No
Yes If yes, reason:
Please continue to the following page.
Medical
Pharmacy
MSA
Graduate
MSTP
MCW STUDENT INSURANCE
SECTION 2: DEPENDENT INFORMATION
Last Name First Name M.I.
Social Security Number
(9 digits, no dashes)
Date of Birth (MMDDYYYY)
Sex: Male Female
Enter information for each dependent (including spouse) you wish to cover under any or all of MCW’s student
insurance offerings. If you do not have dependent(s), you may leave this section blank.
Relationship: Spouse Child Other:
1
Is the dependent disabled? Yes No
If disabled, reason:
Which benet(s) would you like him/her to be enrolled in? Health & Rx Dental
Primary Care Physician Name
Current Patient?
Yes No
HMO Plan Only:
Last Name First Name M.I.
Social Security Number
(9 digits, no dashes)
Date of Birth (MMDDYYYY)
Sex: Male Female
Relationship: Spouse Child Other:
2
Is the dependent disabled? Yes No
If disabled, reason:
Which benet(s) would you like him/her to be enrolled in? Health & Rx Dental
Primary Care Physician Name
Current Patient?
Y
es No
HMO Plan Only:
Please continue to the following page.
2 of 8
SECTION 2: DEPENDENT INFORMATION (Continued)
3 of 8
Last Name First Name M.I.
Social Security Number
(9 digits, no dashes)
Date of Birth (MMDDYYYY)
Sex: Male Female
Relationship: Spouse Child Other:
3
Is the dependent disabled? Yes No
If disabled, reason:
Which benet(s) would you like him/her to be enrolled in? Health & Rx Dental
Primary Care Physician Name
Current Patient?
Yes No
HMO Plan Only:
Last Name First Name M.I.
Social Security Number
(9 digits, no dashes)
Date of Birth (MMDDYYYY)
Sex: Male Female
Relationship: Spouse Child Other:
4
Is the dependent disabled? Yes No
If disabled, reason:
Which benet(s) would you like him/her to be enrolled in? Health & Rx Dental
Primary Care Physician Name
Current Patient?
Yes No
HMO Plan Only:
Use the following alternate address for these dependents: 1 2 3 4
Street Address Apt / Suite / P.O. Box Number
City State ZIP Code
Please continue to the following page.
$3
$
$2
$2
If declining coverage, please submit a copy of your current health insurance card.
SECTION 3: HEALTH INSURANCE (Network Health Plan)
All MCW students are required to have health insurance. You are not required to enroll in the MCW health
insurance offering and you may obtain insurance elsewhere. However, you must elect to decline coverage below
and provide a copy of your insurance card if you choose not to enroll through MCW.
HMO Plan ($250 Deductible)
NPOS Plan ($750 Deductible)
NPOS Plan ($3,000 Deductible)
NPOS Plan ($5,000 Deductible)
Decline Coverage
Single
(monthly)
Family
(monthly)
Single + 1
(monthly)
$6
$7
$5
$4
$1,0
$1,.
$
$741.63
3a
Do you or any of your dependents have other medical insurance? Yes No
Only answer the remaining questions in the section if you answered “Yes” to the previous question.
Name of Insurance Carrier
Plan or Company Name Policyholder Name Effective Date (MMDDYYYY)
Will this coverage continue after July 1, 2019? Yes No
HMO PLAN ONLY
Only complete this section if you elected the HMO plan on the previous page. If you did not choose the HMO plan,
continue to section 3c.
Primary Care Physician
The HMO plan requires you to select a primary care physician. Please refer to your enrollment guide for instructions
on how to nd an in-network physician.
Primary Care Physician Name
Current Patient?
Yes No
Name of Person(s) with Other Insurance
3b
3c
Please continue to the following page.
4 of 8
SECTION 3: HEALTH INSURANCE (Network Health Plan) (Continued)
5 of 8
3d
Waiver (Declining Coverage)
Only complete this section if you elected to decline coverage above.
I acknowledge that I have been given the opportunity to apply for group coverage available to me and my
dependent(s) through MCW. I proclaim that I was not pressured or forced by MCW, the writing agent, or Humana into
waiving (declining) coverage. If I have waived any coverage offered to me or my dependents, my signature at the end
of this form is evidence of this action.
I hereby waive health insurance coverage for (check all that apply): Myself My spouse My dependent(s)
I decline to apply for group coverage because of:
Parental Coverage (must be 26 or younger) Spousal Coverage Individual Coverage
Medicare Supplement Other: _________________________________________________
Please continue to the following page.
SECTION 4: Life, AD&D and LTD Insurance (Anthem)
Enrollment in the MCW Life, Accidental Death & Dismemberment (AD&D) and Long-Term Disability (LTD)
insurance is mandatory for Medical, Pharmacy, MSA and MSTP students.
Medical, Pharmacy, MSA, MSTP
Basic Life/AD&D/LTD Insurance
Single
(monthly)
$5.50
Complete this section. All information is required (including social security numbers) to ensure the correct person
receives the insurance money if something were to happen to you.
Primary Beneciary
Last Name First Name M.I.
Social Security Number (9 digits, no dashes)
Date of Birth (MMDDYYYY)
Relationship to Student
Contingent Beneciary
6 of 8
Last Name First Name M.I.
Social Security Number (9 digits, no dashes)
Date of Birth (MMDDYYYY)
Relationship to Student
Please continue to the following page.
Graduate
Basic Life/AD&D/LTD Insurance
Single
(monthly)
$5.50
Decline
7 of 8
SECTION 5: Dental Insurance CarePlus Dental (Dental Associates and Midwest Dental Network)
CarePlus Dental Plan
Decline Coverage
$15.83 $30.25 $50.98
Single
(monthly)
Family
(monthly)
Single + 1
(monthly)
Please continue to the following page.
All students are eligible, but not required, to elect dental insurance.
CarePlus Dental Associates and Midwest Dental provider locations are available to all campus locations.
Please refer to the Enrollment Guide to find a provider/location.
8 of 8
SECTION 6: AUTHORIZATION & SIGNATURE
I understand, agree and represent:
• I have read this document or it has been read to me and answers provided are true and complete to the best of my
knowledge and belief.
• Neither MCW nor the agent can waive any question, determine coverage or insurability, alter any contact or waive any
of the carriers’ rights and requirements.
• If this application for coverage is accepted, coverage will be effective on the date(s) specified by the carrier(s) on the
certificate of coverage or insurance card.
• If I wish to change enrollment status due to a qualifying event, I may in the future be able to enroll myself or my
dependent(s) provided I request enrollment within 31 days of the qualifying event.
• If I am declining coverage for myself or my dependents (including my spouse) because of other coverage, I may in the
future be able to enroll myself or my dependent(s) provided that I request enrollment within 31 days after my other
coverage ends.
• The carriers reserve the right to delay and/or deny medical coverage, life, LTD, or dental coverage with any future
application for coverage.
• Any misrepresentation contained herein relied on by a carrier may be used to reduce or deny a claim or void the
contract within the contestable period if such misrepresentation materially affected the acceptance of the risk.
• I authorize any third party to have information regarding myself. This includes any medical or non-medical information
and to share any and all such information with the carrier, its reinsurer or its legal representatives, and its affiliates.
• My dependent(s) and I understand and agree:
• The information obtained by use of this authorization may be used by the carrier to make claims determinations,
determine eligibility for coverage, eligibility for benefits under an existing policy and plan administration.
• Any information obtained will not be released by the carrier to any person or organization except to reinsuring
companies, the Medical Information Bureau, Inc. or other persons or organizations performing health care
operations or business or legal services in connection with an application, claim or as may be otherwise lawfully
required, or as I (we) may further authorize. Once personal and health (including but not limited to medical, dental
and pharmacy) information is disclosed pursuant to this authorization, the recipient may redisclose it and the
information may not be protected by federal and state privacy requirements.
• I authorize/elect to receive any and all benefit information electronically (via email or intranet).
Signature of Student or Legal Representative Signature Date (MMDDYYYY)
Name and Relationship of Legal Representative (if applicable)
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2019-20 MCW Student Insurance Enrollment Form (Medical College of Wisconsin)

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Completed 23 August 2020

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