Fillable CA Large Groups Employee Enrollment Form

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CA Large Groups Employee Enrollment Form

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The CA Large Groups Employee Enrollment Form form is 3 pages long and contains:

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Page 1 of 3
LG.EE.18.CA 1/18
400-3689 04/20
To speed the enrollment process, please be thorough and
fill out all sections that apply.
CA Large Groups
Employee Enrollment Form
(DO NOT STAPLE)
UnitedHealthcare Insurance Company
To Be Completed by Employer
Requested Effective Date of Coverage/Date of Change ___/___/___
Group Name: __________________________________________________________________ DBA (if applicable):____________________________________
Product Group # Plan Variation # Reporting Code
Date of Hire _______/_______/_______ Medical
Position/Title
Dental
Hours Worked per Week Vision
Salary $______________ Required only if Life,
STD or LTD Plan based on salary
Life
Reason for Application
New Group Plan New Hire
Life Event/Date
___/___/___
Annual
Status Change
_______
Open
Dependent Add/Delete
Enrollment
Change Name/Address
Late
Waiving Coverage
Enrollee
Other ________________
Rehire
Employee Type (Check all that apply)
Active Union Non-Union
Hourly Salary Other _______
Early Retiree
Retired
COBRA
Cal COBRA
Start date____/____/____ End date____/____/____
Indicate Qualifying Event ______________
Original Qualifying Event Date
Begin date____/____/____ End date____/____/____
Cancellations:
Last Date of Employment
___/___/___
Requested Effective Date of Cancellation ___/___/___
Cancel all coverage
Cancel all listed below – Section B
(family information)
Death Employee Terminated Divorce
Moved out of service area
Dependent reached dependent maximum age
Other (describe)__________________________
A. Employee Information
Last Name First Name MI Social Security Number Home Phone
Work Phone
Address Apt. # City State ZIP E-mail address
Date of Birth
________/________/___________
Sex M
F
Marital Status
Single Married Divorce Widowed Domestic Partner
Primary Care Physician
(1)
Existing Patient Yes No
Name:
_______________________________________________________________________________
Address _____________________________________________________________________________
ID# __________________________________
Complete all sections for all family members.
B. Family Information for Spouse
IMPORTANT: (1) Please use the UnitedHealthcare Provider Directory to select a Primary Care Physician for yourself and each of your covered dependents for
products requiring a Primary Care Physician designation. (2) Please use the Dental Directory to select a Primary Care Dentist for yourself and each of your covered
dependents for products requiring a Primary Care Dentist designation. (3) For court-ordered dependent, legal documentation must be attached. (4) If you answered
“Yes” for Disabled and the dependent child is 26 years of age or older, unmarried, chiefly dependent upon subscriber/covered person 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.
Check
Appropriate
Box
Enroll
Cancel
Change
Last Name First Name MI Sex
M F
Date of Birth
____/____/____
Social Security Number
Address (if different from Employee)
Primary Care Physician
(1)
Existing Patient Yes No
Name:
_____________________________________________________________________
Address ___________________________________________________________________
ID# __________________________________
Relationship
(3)
Spouse/
Domestic
Partner
HMO ONLY
HMO ONLY
Subscriber Last, First Name ______________________________________________ SSN____________________________________________
Page 2 of 3
LG.EE.18.CA 1/18
Complete all sections for all family members. (Attach sheet if necessary)
B. Family Information for Dependents”
Person Medical Dental Vision
Employee
Spouse/Domestic Partner
Dependent
____________
____________
____________
____________
____________
____________
C. Product Selection
IMPORTANT: (1) Please use the Provider Directory to select a Primary Care Physician for yourself and each of your covered dependents for products requiring
a Primary Care Physician designation. (2) Please use the Dental Directory to select a Primary Care Dentist for yourself and each of your covered dependents for
products requiring a Primary Care Dentist designation. (3) For court-ordered dependent, legal documentation must be attached. (4) If you answered “Yes” for Disabled
and the dependent child is 26 years of age or older, unmarried, chiefly dependent upon subscriber/covered person 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.
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.
Check
Appropriate
Box
Enroll
Cancel
Change
Last Name First Name MI Sex
M F
Date of Birth
____/____/____
Social Security Number
Permanently Disabled and age 26 or older
(4)
Yes No
Address (if different from Employee)
Primary Care Physician
(1)
Existing Patient Yes No
Name:
_____________________________________________________________________
Address ___________________________________________________________________
ID# __________________________________
Relationship
(3)
Dependent
Last Name First Name MI Sex
M F
Date of Birth
____/____/____
Social Security Number
Permanently Disabled and age 26 or older
(4)
Yes No
Address (if different from Employee)
Primary Care Physician
(1)
Existing Patient Yes No
Name:
_____________________________________________________________________
Address ___________________________________________________________________
ID# _________________________________
Last Name First Name MI Sex
M F
Date of Birth
____/____/____
Social Security Number
Permanently Disabled and age 26 or older
(4)
Yes No
Address (if different from Employee)
Primary Care Physician
(1)
Existing Patient Yes No
Name:
_____________________________________________________________________
Address ___________________________________________________________________
ID# _________________________________
Relationship
(3)
Dependent
Relationship
(3)
Dependent
Check
Appropriate
Box
Enroll
Cancel
Change
Check
Appropriate
Box
Enroll
Cancel
Change
HMO ONLY
HMO ONLY
HMO ONLY
Basic Life / AD&D
STD / LTD
Subscriber Last, First Name ______________________________________________ SSN____________________________________________
G. Authorization to Release Medical Information and Signature
Your enrollment in the plan is expressly conditioned upon your acceptance of all terms and conditions contained in this enrollment application. If you do not agree to
the following terms and conditions, you may not complete your enrollment.
TERMS AND CONDITIONS
As a condition of my and/or my dependents’ participation in the plan, and in consideration for the privileges that come from participation in the plan, I hereby agree
for myself and/or for my dependents as follows:
I recognize and understand that the plan contracts with physicians and other providers that make up the plan network. I recognize that all physicians and other
providers that participate in the plan network are subject to credentialing under applicable State regulations and pursuant to the plan’s network credentialing
process. I understand that such credentialing includes a review of provider education, training and licensure. However, by participating in the plan I hereby
acknowledge and accept that the plan is not a provider of medical services, and I am aware that obtaining or not obtaining medical care involves significant risks
such as serious injury and even death. I acknowledge that the credentialing of physicians and other providers does not in any way reduce this risk. I agree to
assume all risks and responsibility for any claims including personal injury or death, disability, lost wages, and loss of earning capacity which may be incurred or
associated with medical treatment obtained through a participating physician or other provider. I recognize that all physicians and other providers that participate
in the plan network are independent contractors and not the plan’s employees or agents and are solely responsible for any malpractice, adverse outcomes, or any
other claims arising from medical treatment rendered to me and my dependents. I HEREBY AGREE THAT THE PLAN IS NOT RESPONSIBLE NOR LIABLE
FOR ANY ADVICE, COURSE OF TREATMENT, DIAGNOSIS OR ANY OTHER INFORMATION, SERVICES OR PRODUCTS THAT I OR MY DEPENDENTS
OBTAIN THROUGH A PARTICIPATING NETWORK PHYSICIAN OR OTHER PROVIDER.
I recognize and understand that the plan does not recommend, endorse or make any representation about the appropriateness or suitability of any specific tests,
products, procedures, treatments, services, or opinions. I recognize that the plan, plan documents, and any health and wellness information provided by the plan,
are not intended or implied to be a substitute for professional medical advice, diagnosis or treatment. I agree to confirm any medical information obtained from or
through the plan with other sources, and will review all information regarding any medical condition or treatment with my physician. I HEREBY AGREE TO NEVER
DISREGARD PROFESSIONAL MEDICAL ADVICE OR DELAY SEEKING MEDICAL TREATMENT BECAUSE OF SOMETHING I HAVE READ OR ACCESSED
THROUGH THE PLAN.
I recognize that the plan, plan documents, and any health and wellness information provided by the plan, are not intended or implied to be a substitute for
professional medical advice, diagnosis or treatment.
I authorize UnitedHealthcare Insurance Company and its affiliates (“UnitedHealthcare and Affiliates”) 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, who may be in possession of
my confidential health information, to disclose my information to UnitedHealthcare and Affiliates. I understand this authorization is voluntary and I may refuse to
sign the authorization. My refusal may, however, affect my ability to enroll in the health plan or receive benefits, if permitted by law. I understand I may revoke this
authorization at any time by notifying my UnitedHealthcare and Affiliates representative in writing, except to the extent that action has already been taken in reliance
on this authorization. As required by HIPAA, UnitedHealthcare and Affiliates also request 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 (with the exception of HIV/AIDS health information) and no longer protected by federal privacy
regulations except as prohibited by state law. This authorization, unless revoked earlier, expires 30 months after the date it is signed.
I understand that I am completing a health application and that each response must be complete and accurate. I (we) request the indicated group medical coverage
for myself and, if the plan provides, for my dependents. I authorize any required premium contributions to be deducted from earnings. I (we) have not given the
agent or any other persons any health information not included on the Request for Coverage. I (we) understand that the HMO/insurance company(ies) 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 Request for Coverage and
any attachments. UnitedHealthcare is only seeking to collect information about the current health status of those persons listed on the application. You should not
include any genetic information. Please do not include any family medical history information related to genetic services or genetic diseases for which you believe
you or your dependents may be at risk.
Please maintain a copy of this authorization for your records.
Page 3 of 3
LG.EE.18.CA 1/18
Employee Signature Employee Name (please print) Date
_______/________/_______
I AGREE AND UNDERSTAND THAT ANY AND ALL DISPUTES, INCLUDING CLAIMS RELATING TO THE DELIVERY OF
SERVICES UNDER THE PLAN AND CLAIMS OF MEDICAL MALPRACTICE (THAT IS, AS TO WHETHER ANY MEDICAL
SERVICES RENDERED UNDER THE HEALTH PLAN WERE UNNECESSARY OR UNAUTHORIZED OR WERE IMPROPERLY,
NEGLIGENTLY OR INCOMPETENTLY RENDERED), EXCEPT FOR CLAIMS SUBJECT TO ERISA, BETWEEN MYSELF AND MY
DEPENDENTS ENROLLED IN THE PLAN (INCLUDING ANY HEIRS OR ASSIGNS) AND UNITEDHEALTHCARE OF CALIFORNIA,
UNITEDHEALTHCARE OR ANY OF ITS PARENTS, SUBSIDIARIES OR AFFILIATES, SHALL BE DETERMINED BY SUBMISSION
TO BINDING ARBITRATION. ANY SUCH DISPUTE WILL NOT BE RESOLVED BY A LAWSUIT OR RESORT TO COURT PROCESS,
EXCEPT AS THE FEDERAL ARBITRATION ACT PROVIDES FOR JUDICIAL REVIEW OF ARBITRATION PROCEEDINGS. ALL
PARTIES TO THIS AGREEMENT ARE GIVING UP THEIR CONSTITUTIONAL RIGHTS TO HAVE ANY SUCH DISPUTE DECIDED IN A
COURT OF LAW BEFORE A JURY, AND INSTEAD ARE ACCEPTING THE USE OF BINDING ARBITRATION.
H. Binding Arbitration
Employee Signature (Required) Employee Name (please print) (Required) Date (Required)
_______/________/_______
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CA Large Groups Employee Enrollment Form

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Completed 21 August 2021

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