Fillable Application for Group Enrollment and Change (Dickerson Insurance Services)

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Application for Group Enrollment and Change (Dickerson Insurance Services)

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FRM029107EC00_SBG_CA (1/20)
SBGEEFFORM 1/20
Medical and Life/AD&D plans are provided by Health Net of California, Inc. and/or Health Net Life Insurance Company (together,
“Health Net”). Dental HMO plans, other than pediatric dental, are offered and administered by Dental Benefit Providers of
California, Inc., and dental PPO and indemnity insurance plans, other than pediatric dental, are underwritten by Unimerica Life
Insurance Company and administered by Dental Benefit Administrative Services (together, “DBP”). Vision plans, other than
pediatric vision, are underwritten by Health Net Life Insurance Company and serviced by EyeMed Vision Care, LLC (“EyeMed”) and
Envolve Vision, Inc.
Pediatric dental HMO plans are provided by Health Net of California, Inc. Pediatric dental PPO and indemnity plans are provided
by Health Net Life Insurance Company.
Neither DBP nor EyeMed are affiliated with Health Net. Obligations under dental plans, other than pediatric dental, are not
obligations of, and are not guaranteed by, Health Net.
Welcome to Health Net
SIMPLE STEPS FOR COMPLETING THE FORM:
1. Review the materials enclosed in your enrollment packet. Be sure that you understand the coverage options that are
available to you by your employer.
2a. If you are declining coverage for yourself and/or your dependents, section 7 is required. Do not fill out any other sections.
2b. If you are accepting coverage for yourself and/or your dependents, sections 1, 2, 3, 5, and 8 are required.
The Affordable Care Act (ACA) requires Health Net to provide to the IRS confirmation of health care coverage for yourself,
as the subscriber, and your covered dependents. The IRS uses this information to confirm each member has minimum
essential coverage. We request you provide an accurate Social Security number (SSN) or Tax Identification number (TIN)
for yourself and each dependent you are enrolling. A Matricular ID # is requested for any enrollees residing in Mexico when
enrolling on a Salud HMO y Más plan. For more information about the individual shared responsibility payment provision,
go to http://www.irs.gov/uac/Questions-and-Answers-on-the-Individual-Shared-Responsibility-Provision.
3. If you choose to enroll in the Full HMO, WholeCare HMO, CommunityCare HMO, SmartCare HMO, Salud HMO y Más,
PureCare HSP, or Dental HMO (DHMO) plans, you must select your participating physician group (PPG), primary care
physician (PCP) or dental provider. Be sure to fill in the names and numbers as they appear in Health Net’s online
ProviderSearch tool.
Note: If you do not select a PPG, PCP and/or a dental provider, one will be selected for you.
4. If you choose to enroll in a PPO insurance plan, you are not required to select a PPG or PCP to enroll.
5. Make a copy of the completed application for your records. If a correction is needed, cross out and initial each
correction. Please do not use a white-out product.
Small Business
Application for Group Enrollment
and Change
FOR ADMINISTRATIVE USE ONLY:
Existing Business/Group
PO Box 9103
Van Nuys, CA 91409-9103
www.healthnet.com
New Business/Group
Please send all completed paperwork to your
designated account executive or broker.
FRM029107EC00_SBG_CA (1/20)
SBGEEFFORM 1/20
This page is intentionally left blank
1
FRM029107EC00_SBG_CA (1/20)
SBGEEFFORM 1/20
TO BE COMPLETED BY EMPLOYER
Employer name:
Requested effective date: Employer group number (medical):
Employee eligibility date (new hire only):
■ Same as hired date ■ O t h e r: ____________________________________________________
Important: Please print all sections in black ink. You are entitled to see a Summary of Benefits and Coverage (SBC) before
you choose a plan. Please contact your employer if you do not have the SBC for the plan you have selected.
This page is intentionally left blank
1. Health plan information (All medical plans include pediatric dental and vision coverage.)
FULL HMO NETWORK
1
SMARTCARE HMO NETWORK
2
Platinum
■ $10 ■ $20 ■ $30
Gold
■ $30 ■ $35 ■ $40 ■ $50
Silver
■ $50
Platinum
■ $10 ■ $20 ■ $30
Gold
■ $30 ■ $35 ■ $40 ■ $50
Silver
■ $50
WHOLECARE HMO NETWORK
1
SALUD HMO Y MÁS NETWORK
3
Platinum
■ $10 ■ $20 ■ $30
Gold
■ $30 ■ $35 ■ $40 ■ $50
Silver
■ $50
Platinum
■ $10 ■ $20 ■ $30
Gold
■ $30 ■ $35 ■ $40 ■ $50
Silver
■ $50
COMMUNITYCARE HMO NETWORK
4
Silver ■ $50 Bronze ■ CommunityCare Bronze 60 HMO 6300/65 + Child Dental
PURECARE HSP NETWORK
1
■ PureCare Platinum 90 HSP 0/15 + Child Dental
■ PureCare Gold 80 HSP 250/25 + Child Dental
■ PureCare Silver 70 HSP 2250/50 + Child Dental
■ PureCare Bronze 60 HSP 6300/65 + Child Dental
FULL PPO NETWORK ENHANCEDCARE PPO NETWORK
5
■ Platinum 90 PPO 0/15 + Child Dental
■ Platinum 90 PPO 250/15 + Child Dental Alt
■ Gold 80 PPO 0/30 + Child Dental Alt
■ Gold 80 PPO 250/25 + Child Dental
■ Gold 80 PPO 500/20 + Child Dental Alt
■ Gold 80 PPO 1000/30 + Child Dental Alt
■ Gold 80 Value PPO 750/15 + Child Dental Alt
■ Silver 70 PPO 2250/50 + Child Dental
■ Silver 70 PPO 2250/55 + Child Dental Alt
■ Silver 70 HDHP PPO 1400/40% + Child Dental Alt
■ Silver 70 Value PPO 1700/50 + Child Dental Alt
■ Bronze 60 PPO 6300/65 + Child Dental
■ Bronze 60 HDHP PPO 5600/20% + Child Dental Alt
■ EnhancedCare Platinum 90 PPO 250/15 + Child Dental Alt
■ EnhancedCare Gold 80 PPO 0/30 + Child Dental Alt
■ EnhancedCare Gold 80 PPO 500/20 + Child Dental Alt
■ EnhancedCare Gold 80 PPO 1000/30 + Child Dental Alt
■ EnhancedCare Gold 80 Value PPO 750/15 + Child Dental Alt
■ EnhancedCare Silver 70 PPO 2250/55 + Child Dental Alt
■ EnhancedCare Silver 70 HDHP PPO 1400/40% + Child Dental Alt
■ EnhancedCare Silver 70 Value PPO 1700/50 + Child Dental Alt
■ EnhancedCare Bronze 60 HDHP PPO 5600/20% + Child Dental Alt
OTHER PLANS:
___________________________________________________________________________________________________________________________________________________
DENTAL DHMO DENTAL DPPO VISION PPO
■ HN Plus 150
■ HN Plus 225
■ Classic 5 1500 (w/ortho) ■ Essential 2 1000
■ Essential 6 1500 ■ Classic 4 1500
■ Essential 5 1500 (w/ortho)
■ Elite 1010-1 ■ Supreme 010-2
■ Preferred 1025-2 ■ Preferred 1025-3
■ Preferred Value 10-3 ■ Plus 20-1
■ Exam Only
2. Reason for application
■ Plan change
■ Change address/name
■ Delete dependent
(list names below)
■ Other:
__________________________
■ New hire ■ Open Enrollment
Special Enrollment Period
Qualifying event date: _____ /_____ /_______
■ COBRA
6
Effective date: _____ / _____ / _______
Q u a l i f y i n g e v e n t : __________________________
Qualifying event date: _____ / _____ / _______
Add dependent:
■ Marriage ■ Newborn/Adoption/Legal guardianship/Court order/Assumption of parent-child relationship
■ Loss of prior coverage ■ Domestic partnership ■ O t h e r ( s p e c i f y ) : _________________________________________
Last 4 digits of Social Security #/TIN: ___ ___ ___ ___
E m p l o y e e n a m e : ____________________________________________________________________
2
FRM029107EC00_SBG_CA (1/20)
SBGEEFFORM 1/20
■ Son
■ Daughter
Last name: First name: MI:
Residence address:
■ Check here if same as subscriber
City: State: ZIP:
Date of birth (mm/dd/yyyy): Social Security #/TIN/Matricular ID #:
Participating physician group: Primary care physician:
PPG/PCP Enrollment ID # (4-digit PPG and 6-digit PCP numbers): Is this your current PCP?
■ Yes ■ No
Dental HMO provider name: Dental HMO provider ID #:
3. EMPLOYEE PERSONAL INFORMATION
Last name: First name: MI:
■ Male ■ Female
Residence address:
City: State: ZIP: County:
Date of birth (mm/dd/yyyy): Social Security #/TIN/Matricular ID #: Job title:
Telephone #:
( )
Work phone #:
( )
Email address:
Date of hire:
/ /
Dept. #: Marital status:
■ Single ■ Married ■ Domestic partner
If available, I would prefer to receive communication and plan information in Spanish:
■ Yes ■ No
Participating physician group: Primary care physician:
PPG/PCP Enrollment ID # (4-digit PPG and 6-digit PCP numbers):
Is this your current PCP?
■ Yes ■ No
Dental HMO provider name: Dental HMO provider ID #:
4. Family information, please list all eligible family members to be enrolled.
(Attach additional sheets if necessary.)
Spouse/Domestic partner
■ M ■ F
Last name: First name: MI:
Residence address:
■ Check here if same as subscriber
City: State: ZIP:
Date of birth (mm/dd/yyyy): Social Security #/TIN/Matricular ID #:
Participating physician group: Primary care physician:
PPG/PCP Enrollment ID # (4-digit PPG and 6-digit PCP numbers): Is this your current PCP?
■ Yes ■ No
Dental HMO provider name: Dental HMO provider ID #:
Last 4 digits of Social Security #/TIN: ___ ___ ___ ___
E m p l o y e e n a m e : ____________________________________________________________________
3
FRM029107EC00_SBG_CA (1/20)
SBGEEFFORM 1/20
■ Son
■ Daughter
Last name: First name: MI:
Residence address:
■ Check here if same as subscriber
City: State: ZIP:
Date of birth (mm/dd/yyyy): Social Security #/TIN/Matricular ID #:
Participating physician group: Primary care physician:
PPG/PCP Enrollment ID # (4-digit PPG and 6-digit PCP numbers): Is this your current PCP?
■ Yes ■ No
Dental HMO provider name: Dental HMO provider ID #:
■ Son
■ Daughter
Last name: First name: MI:
Residence address:
■ Check here if same as subscriber
City: State: ZIP:
Date of birth (mm/dd/yyyy): Social Security #/TIN/Matricular ID #:
Participating physician group: Primary care physician:
PPG/PCP Enrollment ID # (4-digit PPG and 6-digit PCP numbers): Is this your current PCP?
■ Yes ■ No
Dental HMO provider name: Dental HMO provider ID #:
4. Family information, please list all eligible family members to be enrolled. (continued)
(Attach additional sheets if necessary.)
Last 4 digits of Social Security #/TIN: ___ ___ ___ ___
E m p l o y e e n a m e : ____________________________________________________________________
4
FRM029107EC00_SBG_CA (1/20)
SBGEEFFORM 1/20
5. Do you or your dependents have other health care coverage?
■ No ■ Yes If “Yes,” please complete this section including Medicare.
■ Self Name: Name of other insurance carrier: Prior coverage start date
(mm/dd/yy):
Prior coverage end
date (mm/dd/yy):
Reason for ending coverage: Group #/Policy ID #: Does it cover?
Medical:
■ Yes ■ No
Dental: ■ Yes ■ No
Vision: ■ Yes ■ No
Medicare:
■ Part A
■ Part B
Medicare claim/
HICN #:
■ Spouse
■ Domestic partner
Name: Name of other insurance carrier: Prior coverage start date
(mm/dd/yy):
Prior coverage end
date (mm/dd/yy):
Reason for ending
coverage:
Group #/
Policy ID #:
Is this your
dependent’s primary
coverage?
■ Yes ■ No
Does it cover?
Medical: ■ Yes ■ No
Dental: ■ Yes ■ No
Vision: ■ Yes ■ No
Medicare:
■ Part A
■ Part B
Medicare claim/
HICN #:
■ Son
■ Daughter
Name: Name of other insurance carrier: Prior coverage start date
(mm/dd/yy):
Prior coverage end
date (mm/dd/yy):
Reason for ending
coverage:
Group #/
Policy ID #:
Is this your
dependent’s
primary coverage?
■ Yes ■ No
Does it cover?
Medical: ■ Yes ■ No
Dental: ■ Yes ■ No
Vision: ■ Yes ■ No
Medicare:
■ Part A
■ Part B
Medicare claim/
HICN #:
■ Son
■ Daughter
Name: Name of other insurance carrier: Prior coverage start date
(mm/dd/yy):
Prior coverage end
date (mm/dd/yy):
Reason for ending
coverage:
Group #/
Policy ID #:
Is this your
dependent’s
primary coverage?
■ Yes ■ No
Does it cover?
Medical: ■ Yes ■ No
Dental: ■ Yes ■ No
Vision: ■ Yes ■ No
Medicare:
■ Part A
■ Part B
Medicare claim/
HICN #:
■ Son
■ Daughter
Name: Name of other insurance carrier: Prior coverage start date
(mm/dd/yy):
Prior coverage end
date (mm/dd/yy):
Reason for ending
coverage:
Group #/
Policy ID #:
Is this your
dependent’s
primary coverage?
■ Yes ■ No
Does it cover?
Medical: ■ Yes ■ No
Dental: ■ Yes ■ No
Vision: ■ Yes ■ No
Medicare:
■ Part A
■ Part B
Medicare claim/
HICN #:
1
Available in all or parts of Alameda, Contra Costa, El Dorado, Fresno, Kern, Kings, Los Angeles, Madera, Marin, Merced, Napa, Nevada, Orange, Placer, Riverside, Sacramento,
San Bernardino, San Diego, San Francisco, San Joaquin, San Mateo, Santa Barbara, Santa Clara, Santa Cruz, Solano, Sonoma, Stanislaus, Tulare, Ventura, and Yolo counties.
2
Available in all or parts of Los Angeles, Orange, Riverside, San Diego, San Bernardino, Santa Clara, and Santa Cruz counties.
3
Available in Orange County and select ZIP codes of Kern, Los Angeles, Riverside, San Diego, and San Bernardino counties.
4
Available in Los Angeles, Orange and San Diego counties.
5
Available in Los Angeles County.
6
Provide the effective date COBRA first began, whether you were eligible for a total of 18 months or 36 months of COBRA (including Cal-COBRA).
“Plan Contract” refers to the Health Net of California, Inc. and/or Dental Benefit Providers of California, Inc. Group Service Agreement and
Evidence of Coverage; “Insurance Policy” refers to Health Net Life Insurance Company, Unimerica Life Insurance Company Group Policy
and Certificate of Insurance.
6. Group term life insurance, if applicable. (Attach separate sheet for additional or contingent beneficiaries.)
Life/AD&D coverage: ■ Yes ■ No
Life beneficiary (full name):
Relationship: %
Life beneficiary (full name):
Relationship: %
Life beneficiary (full name):
Relationship: %
Life beneficiary (full name):
Relationship: %
Last 4 digits of Social Security #/TIN: ___ ___ ___ ___
E m p l o y e e n a m e : ____________________________________________________________________
5
FRM029107EC00_SBG_CA (1/20)
SBGEEFFORM 1/20
7. Declination of coverage (Complete this section if any coverage is being declined by you or your eligible dependents.)
EMPLOYEE PERSONAL INFORMATION
Last name: First name: MI: Social Security #/Matricular ID #:
Declining medical coverage for:
■ Self ■ Spouse ■ Domestic partner ■ Dependent(s)
Name(s):
______________________________________________________
Declining dental coverage for:
■ Self ■ Spouse ■ Domestic partner ■ Dependent(s)
Name(s):
______________________________________________________
Declining vision coverage for:
■ Self ■ Spouse ■ Domestic partner ■ Dependent(s)
Name(s):
______________________________________________________
Reason:
■ Other group coverage through this employer ■ Individual coverage
■ Other group coverage by another group (i.e., spouse’s employer)
■ Other:
___________________________________________________________________
Reason: ■ Other group coverage through this employer ■ Individual coverage
■ Other group coverage by another group (i.e., spouse’s employer)
■ Other:
___________________________________________________________________
Reason: ■ Other group coverage through this employer ■ Individual coverage
■ Other group coverage by another group (i.e., spouse’s employer)
■ Other:
___________________________________________________________________
IF YOU ARE DECLINING COVERAGE  STOP AND READ CAREFULLY
I have decided to decline coverage for myself and/or my dependent(s). I acknowledge that my dependents and I may have to wait to
be enrolled until the next annual Open Enrollment Period or Special Enrollment Period due to a qualifying event. The available coverages have
been explained to me by my employer, and I have been given the chance to apply for the available coverages. Additionally, by signing below, I
certify, to the best of my knowledge or belief, that the reason I am declining coverage is accurate as indicated by the check marks above.
Employee signature: ________________________________________________________________________________________________ Date: _____________________________
(Sign only if declining coverage. If signed in error, please cross out and initial.)
8. Acceptance of coverage (Signature required.)
California law prohibits an HIV test from being required or used by health insurance companies as a condition of obtaining
health insurance coverage.
ACKNOWLEDGMENT AND AGREEMENT: I understand and agree that by enrolling with or accepting services from Health Net and/or
DBP I and any enrolled dependents are obligated to understand and abide by the terms, conditions and provisions of the Plan Contract
or Insurance Policy. I represent that I have read and understand the terms of this application, and my signature below indicates that the
information entered in this application is complete, true and correct to the best of my knowledge and belief, and I accept these terms.
BINDING ARBITRATION AGREEMENT: I, the Applicant, understand and agree that any
and all disputes between me (including any of my enrolled family members or heirs or
personal representatives) and Health Net, except disputes concerning adverse benefit
determinations as defined in 45 CFR 147.136, arising from or relating to the Evidence of
Coverage or Certificate of Insurance or my Health Net coverage, must be submitted to
individual, final and binding arbitration instead of a jury or court trial, and that I am waiving
all rights to class arbitration. This agreement to arbitrate applies even if other parties,
such as health care providers or their agents or employees, are involved in the dispute. I
understand that, by agreeing to submit all disputes, except disputes concerning adverse
benefit determinations, to final and binding arbitration, all parties including Health Net
are giving up their constitutional right to have their dispute decided in a court of law by a
jury. I also understand that disputes that I may have with Health Net involving claims for
medical malpractice (that is, whether any medical services rendered were unnecessary or
unauthorized or were improperly, negligently or incompetently rendered) are also subject
to final and binding arbitration. I understand that a more detailed arbitration provision is
included in the Evidence of Coverage or Certificate of Insurance. Mandatory Arbitration
may not apply to certain disputes if the Employer’s plan is subject to ERISA, 29 U.S.C. §§
1001-1461. My signature below indicates that I understand and agree with the terms of
this Binding Arbitration Agreement and agree to submit any disputes, except disputes
concerning adverse benefit determinations, to binding arbitration instead of a court of law.
Employee signature: __________________________________________________________________________________________________ Date: _______________________
(Sign only if accepting coverage. If signed in error, please cross out and initial.)
Health Net of California, Inc. and Health Net Life Insurance Company are subsidiaries of Health Net, LLC. Health Net and Salud con Health Net are registered service marks of Health Net, LLC.
All other identified trademarks/service marks remain the property of their respective companies. All rights reserved.
6
FRM029107EC00_SBG_CA (1/20)
SBGEEFFORM 1/20
Please contact the HealthNet Customer Contact Center
at the toll-free numbers below if you need assistance in
completing this form or if you have questions about your
coverage:
English 1-800-522-0088
Cantonese 1-877-891-9053
Korean 1-877-339-8596
Mandarin 1-877-891-9053
Spanish 1-800-331-1777
Tagalog 1-877-891-9051
Vietnamese 1-877-339-8621
If you have questions about your dental, vision or life
coverage, please call:
Dental 1-866-249-2382
Vision 1-866-392-6058
Life 1-800-865-6288
If you have questions about your PPG or PCP, call your
PPG directly, or contact HealthNet Provider Services at
1-800-641-7761.
You can use your copy of the HealthNet enrollment form
as your temporary ID card until you receive your permanent
ID card.
EMERGENCY AND URGENTLY NEEDED CARE
• If your situation is life-threatening or an emergency: Call
911 or go to the nearest hospital.
• If your situation is not so severe: If you cannot call your
primary care physician or physician group, or you need
medical care right away, go to the nearest hospital or
urgent care center.
• If you are outside your physician group’s service area: Go
to the nearest hospital, medical center or call 911. In all
cases, contact your primary care physician or participating
physician group as soon as possible to inform them about
your condition.
• Call the number on your ID card within 48 hours of being
admitted, or as soon as possible.
PRECERTIFICATION
You, the member, are responsible for obtaining certification
for certain services. Please check your plan certificate for a
list of services requiring precertification.
For precertification, please call 1-800-977-7282.
DISABLING CONDITIONS
If you or your family member were disabled as of the date
of termination of coverage with a prior health insurer, and
the loss of coverage was due to the termination of the
employer’s insurance policy, you may be entitled to an
extension of health benefits according to California Insurance
Code section 10128. Under this law, the prior insurer retains
responsibility until whichever of the following occurs first: (a)
the member is no longer totally disabled, (b) the maximum
benefits of the prior insurer’s coverage are paid, or (c) a
period of 12 consecutive months has passed since the date
coverage ended with prior insurer.
PRODUCTSENTITIES
HealthNet of California, Inc. offers the following products:
PureCare HSP Network, CommunityCare HMO Network,
Full HMO Network, WholeCare HMO Network, SmartCare
HMO Network, and Salud HMO y Más Network.
HealthNet Life Insurance Company offers the following
products: PPO, EnhancedCare PPO, Life and AD&D insurance.
Dental Benefit Providers of California, Inc. offers the following
products: Dental HMO (DHMO).
Unimerica Life Insurance Company offers the following
products: Dental PPO and Dental Indemnity.
HealthNet Life Insurance Company offers the following
products serviced by EyeMed Vision Care, LLC (“EyeMed”)
and Envolve Vision, Inc.: PPO Vision.
DECLINATION OF COVERAGE
If you decline coverage for yourself or an eligible dependent
because of coverage under other health insurance and you
lose that coverage, or if you acquire a new dependent due to
marriage, domestic partnership, birth, adoption, placement
for adoption, or assumption of parent-child relationship, you
and your dependent may be eligible for special enrollment
rights. You must request special enrollment within 60 days of
the loss of coverage or acquisition of a new dependent.
7
FRM029107EC00_SBG_CA (1/20)
SBGEEFFORM 1/20
Nondiscrimination Notice
In addition to the State of California nondiscrimination requirements (as described in benefit coverage documents), Health Net
of California, Inc. and Health Net Life Insurance Company (Health Net) comply with applicable federal civil rights laws and do
not discriminate, exclude people or treat them differently on the basis of race, color, national origin, ancestry, religion, marital
status, gender, gender identity, sexual orientation, age, disability, or sex.
HEALTH NET:
• Provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language
interpreters and written information in other formats (large print, accessible electronic formats, other formats).
• Provides free language services to people whose primary language is not English, such as qualified interpreters and
information written in other languages.
If you need these services, contact Health Net’s Customer Contact Center at:
Individual & Family Plan (IFP) Members On Exchange/Covered California 1-888-926-4988 (TTY: 711)
Individual & Family Plan (IFP) Members Off Exchange 1-800-839-2172 (TTY: 711)
Individual & Family Plan (IFP) Applicants 1-877-609-8711 (TTY: 711)
Group Plans through Health Net 1-800-522-0088 (TTY: 711)
If you believe that Health Net has failed to provide these services or discriminated in another way based on one of the
characteristics listed above, you can file a grievance by calling Health Net’s Customer Contact Center at the number above and
telling them you need help filing a grievance. Health Net’s Customer Contact Center is available to help you file a grievance.
You can also file a grievance by mail, fax or email at:
Health Net of California, Inc./Health Net Life Insurance Company Appeals & Grievances
PO Box 10348, Van Nuys, CA 91410-0348
Fax: 1-877-831-6019
Email: Member.Discrimination.Complaints@healthnet.com (Members) or
Non-Member.Discrimination.Complaints@healthnet.com (Applicants)
For HMO, HSP, EOA, and POS plans offered through Health Net of California, Inc.: If your health problem is urgent, if you
already filed a complaint with Health Net of California, Inc. and are not satisfied with the decision or it has been more than
30 days since you filed a complaint with Health Net of California, Inc., you may submit an Independent Medical Review/
Complaint Form with the Department of Managed Health Care (DMHC). You may submit a complaint form by calling the DMHC
Help Desk at 1-888-466-2219 (TDD: 1-877-688-9891) or online at www.dmhc.ca.gov/FileaComplaint.
For PPO and EPO plans underwritten by Health Net Life Insurance Company: You may submit a complaint
by calling the California Department of Insurance at 1-800-927-4357 or online at https://www.insurance.ca.gov/
01-consumers/101-help/index.cfm.
If you believe you have been discriminated against because of race, color, national origin, age, disability, or sex, you can also
file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights (OCR), electronically
through the OCR Complaint Portal, at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department
of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC 20201,
1-800-368-1019 (TDD: 1-800-537-7697).
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
8
FRM029107EC00_SBG_CA (1/20)
SBGEEFFORM 1/20
English
No Cost Language Services. You can get an interpreter. You can get documents read to you and some sent
to you in your language. For help, if you have an ID card, please call the Customer Contact Center number.
Employer group applicants please call Health Net’s Commercial Contact Center at 1-800-522-0088 (TTY: 711).
Individual & Family Plan (IFP) applicants please call 1-877-609-8711 (TTY: 711).
Arabic


TTY: 711( 1-800-522-0088Health Net
TTY: 711( 1-877-609-8711
Armenian
Անվճար լեզվական ծառայթյններ: Դք կարող եք բանավոր թարգմանիչ ստանալ:
Փաստաթղթերը կարող են կարդալ ձեր լեզվով: Եթե ID քարտ նեք, օգնթյան համար խնդրմ
ենք զանգահարել Հաճախորդների սպասարկման կենտրոնի հեռախոսահամարով: Գործատի
խմբի դիմորդներին խնդրմ ենք զանգահարել Health Net-ի Կորցիոն սպասարկման կենտրոն՝
1-800-522-0088 հեռախոսահամարով (TTY՝ 711): Individual & Family Plan (IFP) դիմորդներին
խնդրմ ենք զանգահարել 1-877-609-8711 հեռախոսահամարով (TTY՝ 711):
Chinese
免費語言服務。您可使用口譯員服務。您可請人將文件唸給您聽並請我們將某些文件翻譯成您的語言
寄給您。如需協助且如果您有會員卡，請撥打客戶聯絡中心電話號碼。雇主團保計畫的申請人請撥打
1-800-522-0088（聽障專線：711）與 Health Net 私人保險聯絡中心聯絡。Individual & Family Plan (IFP)
的申請人請撥打 1-877-609-8711（聽障專線：711）。
Hindi


      
   TTY
  TTY

Hmong
Tsis Muaj Tus Nqi Pab Txhais Lus. Koj tuaj yeem tau txais ib tus kws pab txhais lus. Koj tuaj yeem muaj ib
tus neeg nyeem cov ntaub ntawv rau koj ua koj hom lus hais. Txhawm rau pab cuam, yog tias koj muaj daim
npav ID, thov hu rau Neeg Qhua Lub Chaw Tiv Toj tus npawb. Tus tswv ntiav neeg ua haujlwm pab pawg sau
ntawv thov ua haujlwm thov hu rau Health Net Qhov Chaw Tiv Toj Kev Lag Luam ntawm
1-800-522-0088 (TTY: 711). Tus Neeg thiab Tsev Neeg Qhov Kev Npaj (IFP) cov neeg thov ua haujlwm thov
hu rau 1-877-609-8711 (TTY: 711).
Japanese
無料の言語サービスを提供しております。通訳者もご利用いただけます。日本語で文書をお読みす
ることも可能です。ヘルプについては、IDカードをお持ちの場合は顧客連絡センターまでお電話く
ださい。雇用主を通じた団体保険の申込者の方は、Health Netの顧客連絡センター
(1-800-522-0088、TTY: 711) までお電話ください。個人・家族向けプラン (IFP) の申込者の方
は、1-877-609-8711 (TTY: 711) までお電話ください。
9
FRM029107EC00_SBG_CA (1/20)
SBGEEFFORM 1/20
Khmer

  



  

 


 


Korean
무료 언어 서비스입니다. 통역 서비스를 받으실 수 있습니다. 문서 낭독 서비스를 받으실 수 있으며
일부 서비스는 귀하가 구사하는 언어로 제공됩니다. 도움이 필요하시면 ID 카드에 수록된 번호로
고객서비스 센터에 연락하십시오. 고용주 그룹 신청인의 경우 Health Net의 상업 고객서비스 센터에
1-800-522-0088(TTY: 711)번으로 전화해 주십시오. 개인 및 가족 플랜(IFP) 신청인의 경우
1-877-609-8711(TTY: 711)번으로 전화해 주십시오.
Navajo
Doo b33h 7l7n7g00 saad bee h1k1 ada’iiyeed. Ata’ halne’7g77 da [a’ n1 h1d7d0ot’88[. Naaltsoos da t’11
sh7 shizaad k’ehj7 shich9’ y7dooltah n7n7zingo t’11 n1 1k0dooln77[. !k0t’4ego sh7k1 a’doowo[ n7n7zingo
Customer Contact Center hooly4h7j8’ hod77lnih ninaaltsoos nanitingo bee n44ho’dolzin7g77 hodoonihj8’
bik11’. Naaltsoos nehilts0osgo naanish b1 dahikah7g77 47 koj8’ hod77lnih
Health Net’s Commercial
Contact Center 1-800-522-0088 (TTY: 711). T’11 h0 d00 ha’1[ch7n7 (IFP) b1h7g77 47 koj8’ hojilnih
1-877-609-8711 (TTY: 711).
Persian (Farsi)





IFPTTY:711( 1-800-522-0088Health Net
TTY:711( 1-877-609-8711
Panjabi (Punjabi)
 

    
TTYIFP  
TTY
Russian
Бесплатная помощь переводчиков. Вы можете получить помощь переводчика. Вам могут прочитать
документы на Вашем родном языке. Если Вам нужна помощь и у Вас при себе есть карточка
участника плана, звоните по телефону Центра помощи клиентам. Участники коллективных планов,
предоставляемых работодателем: звоните в коммерческий центр помощи Health Net по телефону
1‑800‑522‑0088 (TTY: 711). Участники планов для частных лиц и семей (IFP): звоните по телефону
1-877-609-8711 (TTY: 711).
10
FRM029107EC00_SBG_CA (1/20)
SBGEEFFORM 1/20
Spanish
Servicios de idiomas sin costo. Puede solicitar un intérprete, obtener el servicio de lectura de documentos y
recibir algunos en su idioma. Para obtener ayuda, si tiene una tarjeta de identicación, llame al número del
Centro de Comunicación con el Cliente. Los solicitantes del grupo del empleador deben llamar al Centro
de Comunicación Comercial de Health Net, al 1‑800‑522‑0088 (TTY: 711). Los solicitantes de planes
individuales y familiares deben llamar al 1-877-609-8711 (TTY: 711).
Tagalog
Walang Bayad na Mga Serbisyo sa Wika. Makakakuha kayo ng interpreter. Makakakuha kayo ng mga
dokumento na babasahin sa inyo sa inyong wika. Para sa tulong, kung mayroon kayong ID card, mangyaring
tumawag sa numero ng Customer Contact Center. Para sa mga grupo ng mga aplikante ng tagapag-empleyo,
mangyaring tumawag sa Commercial Contact Center ng Health Net sa 1-800-522-0088 (TTY: 711).
Para sa mga aplikante ng Planong Pang-indibiduwal at Pampamilya (Individual & Family Plan, IFP),
mangyaring tumawag sa 1-877-609-8711 (TTY: 711).
Thai





Vietnamese
Các Dịch Vụ Ngôn Ngữ Miễn Phí. Quý vị có thể có một phiên dịch viên. Quý vị có thể yêu cầu được đọc cho
nghe tài liệu bằng ngôn ngữ của quý vị. Để được giúp đỡ, nếu quý vị có thẻ ID, vui lòng gọi đến số điện thoại
của Trung Tâm Liên Lạc Khách Hàng. Những người nộp đơn xin bảo hiểm nhóm qua hãng sở vui lòng gọi
Trung Tâm Liên Lạc Thương Mại của Health Net theo số 1‑800‑522‑0088 (TTY: 711). Người nộp đơn thuộc
Chương Trình Cá Nhân & Gia Đình (IFP), vui lòng gọi số 1‑877‑609‑8711 (TTY: 711).
CA Commercial On and Off-Exchange Member Notice of Language Assistance
FLY017550EH00 (12/17)
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Application for Group Enrollment and Change (Dickerson Insurance Services)

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Completed 1 June 2021

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