Fillable Form 800: Change Request Form A Check here

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Form 800: Change Request Form A Check here

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The Form 800: Change Request Form A Check here form is 5 pages long and contains:

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  • 32 check-boxes
  • 264 other fields

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Employee First Name
M.I.
City
County
Employee Social Security #
Check here if new address:
(Address changes will be effective the 1st day of the month following the receipt of the request)
Physical Address (Do not use P.O. Box)
Apt. #
Check here if changes are to be effective at Renewal
Company Name
Name Change/Correction
New First Name
New Last Name
Cancellations of coverage will take effect on the last day of the month after receipt of your request by CaliforniaChoice®. Cancellations at Renewal will take
effect on the group’s Renewal date.
Additions (qualifying/triggering event)
: Please refer to administrative handbook for effective date guidelines based on qualifying/triggering event.
Additions (at renewal)
: Coverage will be effective on the group's renewal date.
This form must be received by CaliforniaChoice no later than 60 days
after the event takes place if outside renewal.
IF APPLICABLE:
Date of marriage*/divorce if
adding/cancelling spouse
If child custody*, enter
date of adoption
*Attach copy of marriage license and/or certificate as applicable *Attach copy of legal documentation
Coverage Type
Last Name
First Name
Social Securit
y
#
Gende
r
Disabled?
Spouse/Domestic Partner
Child 3
Employee
Male Female
Male Female Male Female
Male Female
Yes No
Yes No Yes No
Reason for
Cancellation
(1 of 5) CC 0500 12/2018 Eff. 4/1/2019
Change Request Form
Complete Employee Information
Only Complete to Cancel Coverage or Add Dependents
MM/DD/YYYY MM/DD/YYYY
Date of Birth
Social Security # required! Social Security # required! Social Security # required! Social Security # required!
MM/DD/YYYY MM/DD/YYYY MM/DD/YYYY MM/DD/YYYY
721 South Parker, Suite 200, Orange, CA 92868
(
800
)
558-8003 www.calchoice.com
•
Do not use this form to change your physician or dentist
Fax completed form to
(
714
)
558-8000 or
•
E-mail to: memberprocessing@calchoice.com
•
IF ADDING DEPENDENT(S): By signing this document I declare under the penalty of perjury
under the laws of the state of California that the
following statements are true and correct regarding the enrolling dependents
, as applicable:
I understand
that I may be asked for legal proof of the above at any time.
My spouse and I are legally married as recognized by the state of California.
My children's dates of birth are accurate. My children are born to me or my spouse/domestic partner, or legally adopted, or a non-temporary legal ward,
and/or have an established parent-child relationship with me or my spouse/domestic partner.
(continued on next page)
PLEASE READ & SIGN THE BACK OF THIS FORM
Complete steps A through E as applicable
(Complete only
if over age 26)
To enroll more dependents, complete sections A & B on an additional Change Request Form.
A
B
Medical
Dental
Voluntary Vision
Residential Address
Mailing
State ZIP Code
New M. I.
Child 2Child 1
Voluntary Vision
Dental
Medical
A
dd Cancel
Voluntary Vision
Dental
Medical
A
dd Cancel
Voluntary Vision
Dental
Medical
A
dd Cancel
Voluntary Vision
Dental
Medical
A
dd Cancel
Cancel
Employee Last Name
Group #
Phone # (XXX) XXX-XXXX
-
-
12356
IF ADDING DEPENDENT(S) (continued)
Last Name
First Name
Primary Care Physician**
Current Patient?
Provider ID#
Provider City
Check here if you would like your Health Plan to assign you a Primary Care Physician.
If changing Health Plan, please select a Primary Care Physician (PCP). A PCP is not required for Kaiser Permanente, EPO and PPO benefit plans. If a
PCP is not contracted with your selected Health Plan prior to enrolling or if a PCP is not listed, one will automatically be assigned to you. If remaining with
the same Health Plan, but changing your benefit plan, please contact the Health Plan directly to confirm your PCP. For PCP changes only, please contact
your Health Plan directly.
**
(2 of 5) CC 0500A 12/2018 Eff. 4/1/2019
(continued on next page)
IMPORTANT: Regarding Steps C and D, plan changes are only allowed at Renewal. However, employees who acquire a new
dependent (i.e. newborn, new spouse etc.) are able to change their coverage outside of the Renewal Period.
Print Employee Name
Group #
Yes No Yes No Yes No Yes No Yes No
Child 3Child 2Child 1Spouse/Domestic Partne
r
Emplo
y
ee
Only Complete to Add/Change your benefit plan
C
I understand that any persons, business, or health plan that suffers a loss because of false declarations contained in this statement may have cause to bring
civil action against me to recover their losses.
I have READ, UNDERSTAND and ATTEST that I myself and my dependents have met all of the eligibility requirements.
The representations made are the basis upon which coverage may be issued. The coverage may be cancelled or the employer's contract rescinded because
of the performance of an act or practice constituting fraud or making of an intentional misrepresentation of a material fact to an insurance company for the
purposes of defrauding the company.
ADD CHANGE
(CHECK ONE)
IMPORTANT: Please select ONE
benefit plan
from the metal tier(s) shown on your Enrollment Worksheet.
If my plan is rescinded or canceled, I will receive from my insurer a notice at least 30 days prior to the effective date of the rescission explaining the reasons
for the intended rescission and my right to appeal that decision to the Commissioner of Insurance pursuant to subdivision (b) of Section 10273.4 of the
California Insurance code. Notwithstanding subdivision (a) of Section 10273.4 or any other provision of the law, I understand that after 24 months following
the issuance of my health plan or insurance policy, my insurer may not rescind my health plan or insurance policy for any reason, and shall not cancel my
health plan or insurance policy, limit any provisions of the health plan or policy, or raise premiums due to any omissions, misrepresentations, or inaccuracies
in the application for, whether willful or not.
ll statements and answers I have given are true and complete. I understand it is a crime to knowingly perform an act or practice constituting fraud or make
an intentional misrepresentation of material fact to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment,
fines or a denial of insurance benefits. I understand all benefits are subject to conditions stated in the Group Contract and coverage documents.
*HSA Qualified High Deductible Plan
WESTERN HEALTH
ADVANTAGE
UNITEDHEALTHCARE
SHARP
KAISER PERMANENTE
HEALTH NET
ANTHEM BLUE CROSS
HEALTH PLAN BRONZE
SILVER GOLD PLATINUM
SUTTER HEALTH PLUS
HSP A
EPO A
HMO A
HMO A
HMO B*
HMO A
HMO B*
HMO B*
HMO B
HMO C*
HMO A
EPO A
HSP A
HMO B
HMO A
HMO B
HMO B
HMO A
HMO B
HMO C*
HMO B
HMO A
HMO D
HMO C
HMO C*
PPO B
PPO A HMO A
HMO B
HMO A
HMO B
HMO A
HMO B
HMO A
HMO B
HMO A
HMO B
HMO A
HMO B
HMO A
HMO C
PPO B
PPO A
PPO D
PPO C
HMO A
HMO C
HMO A
HMO A
HMO B
HMO A
HMO B
HMO A
HMO B
HMO C
HMO A
HMO B
EPO B*
HMO C*
HMO C
HMO C
HMO C
HMO D*
HMO D*
HMO C HMO D HMO C
HMO B
HMO A
HMO D
HMO B
HMO E
HMO D
HMO E
OSCAR
EPO A*
EPO B
EPO A*
EPO B
EPO A
EPO B
EPO C EPO A
EPO B
HMO A
HMO D
EPO D
EPO C
12356
(CHECK
ONE)
Plan 1000/3000 requires selection of a family dentist. Upon receipt
of dental ID cards, you may elect other dentists for dependents.
Prepaid 1000 Prepaid 3000 Voluntary Prepaid 1000 Voluntary Prepaid 3000 PPO 3000
PPO 3500
PPO 4000
PPO 5000
ADD
CHANGE
Dentist's Name
(If left blank or dentist unavailable, one will be assigned)
ID#
Dental Benefit Design Change/Add
Life Insurance Beneficiary Change
Complete only if you wish to change the existing beneficiary on your life insurance. This change will take effect on the date it was signed.
I hereby revoke any previous designation of beneficiary and settlement provisions and make the following beneficiary designation with respect
to any insurance payable at my death under the group plan (including any Group Life Insurance or Group Accidental Death and Dismemberment
Insurance)
Beneficiar
y
Name
(
s
)
Last Name First Name M.I. Date of Birth
Relationship to You
(i.e. spouse, friend, child)
*Percentage
*Type of
Beneficiary
Primary
Secondary
Primary
Secondary
Primary
Secondary
If you are listing more than one primary beneficiary or more than one secondary beneficiary, please enter the percentage of the insurance proceeds that
each individual should receive. The percentage of insurance proceeds must equal 100% for each type of beneficiary (primary or secondary). No secondary
beneficiaries will be entitled to any part of the insurance proceeds if any primary beneficiary is living at the time of death of the insured. To list more
beneficiaries, please submit an additional page and complete Section D.
*
Your Legal Acknowledgement and Mandatory
Binding Arbitration Agreement
(Read, sign and date where indicated)
E
By submitting this signed application, I agree and understand that the health plan I have chosen through the CaliforniaChoice®
program shall automatically have a lien on any payment of monies from any source, for services rendered in conjunction with an injury
caused by the acts or omissions of a third party.
I agree for myself and my dependents to be bound by the benefits, copays, deductibles, exclusions, limitations and other terms of the health
plan’s small group contract.
I authorize my physician, healthcare provider, hospital, clinic or other medically related facility to furnish my, and my dependent’s, protected
health information, including medical records, to the health plan I have chosen through the CaliforniaChoice program or its authorized agents
for the purpose of review, investigation, or evaluation of an application or claim, and for quality assurance and utilization review. I authorize
CaliforniaChoice and the health plan I have chosen, and their agents, designees or representatives, to disclose to a hospital, health plan,
insurer or healthcare provider any protected health information if such disclosure is necessary to allow the performance of any of those
activities. This authorization shall become effective immediately and shall remain in effect for up to 30 months from the date the authorization
was signed. I understand that I, or a person authorized to act on my behalf, is entitled to receive a copy of this authorization form.
I have read and understand the information provided to me pertaining to the Premium Only Plans and the tax consequences.
(continued on next page)
(3 of 5) CC 0500B 12/2018 Eff. 4/1/2019

Group #
Print Employee Name
Only Complete to Add/Change Optional Benefits
D
†
†
Check if current dentist
Check if you would like
a dentist assigned
MM/DD/YYYY
MM/DD/YYYY
MM/DD/YYYY
V
oluntary Vision Change/Add
ADD
CHANGE
Voluntary EyeMed (provided by Ameritas)*
Voluntary VSP (provided by Ameritas)*
Vision One Discount Plan (No Charge)
*Employee is responsible for 100% of this cost if selected for coverage
††
†
(CHECK
ONE)
12356
Today's Date (MM/DD/YYYY)
/ /
E
Your Legal Acknowledgement and Mandatory
Binding Arbitration Agreement (Continued)
(Read, sign and date where indicated)
E
California law prohibits an HIV test from being required or used by health care service plans as a condition of obtaining coverage.
MANDATORY BINDING ARBITRATION
I understand that, if I select a Health Plan that uses mandatory binding arbitration to resolve disputes, I am agreeing
to arbitrate claims that relate to my or a dependent's membership in the Health Plan (except for Small Claims Court
cases and claims that cannot be subject to binding arbitration under governing law). I understand
that any dispute
between myself, my heirs, relatives, or other associated parties on the one hand and the Health Plan, any contracted
health care providers, administrators, or other associated parties on the other hand for alleged violation of any duty
arising out of or related to membership in the Health Plan, including any claim for medical or hospital malpractice (a
claim that medical services were unnecessary or unauthorized or were improperly, negligently, or incompetentl
y
rendered), for premises liability, or relating to the coverage for, or delivery of, services or items, irrespective of legal
theory, must be decided by binding arbitration under California law and not by lawsuit or resort to court process,
except as applicable law provides for judicial review of arbitration proceedings. I agree
to give up our right to a jur
y
trial and accept the use of binding arbitration. I understand that the full arbitration provision is in the Health Plan's
coverage document, which is available for my review.
Em
p
lo
y
ee SIGN HERE
Print Name
My signature acknowledges that I have read Section E, the applicable mandatory binding arbitration of the plan I selected in Section C and my decision to
enroll in the medical, dental, life or vision coverage that I selected in Sections C and D.
(4 of 5) CC 0500C 12/2018 Eff. 4/1/2019
Print Employee Name
Group #
I declare under the penalty of perjury under the laws of the state of California that the following statements are true, correct and
pertain to the employer named on this application, myself and my dependents named on this application.
• I am either actively, permanently working for the employer and considered eligible by my employer because I work either 20+ or 30+
hours per week, or I am an eligible COBRA/Cal-COBRA participant.
• I am not a temporary, seasonal, per diem, 1099 or substitute employee or insured by or eligible to be insured by the employer’s union
policy.
• I have READ, UNDERSTAND and ATTEST that I myself and my dependents have met all of the eligibility requirements.
• The coverage may be cancelled or the employer’s contract rescinded because of the performance of an act or practice constituting fraud
or making of an intentional misrepresentation of a material fact to an insurance company for the purposes of defrauding the company.
• The representations made are the basis upon which coverage may be issued.
I understand that any persons, business or health plan that suffers a loss because of false-declarations contained in this statement may
take legal action against me to recover their losses.
A
ll statements and answers I have given are true and complete. I understand it is a crime to knowingly perform an act or practice
constituting fraud or make an intentional misrepresentation of material fact to an insurance company for the purpose of defrauding the
company. Penalties may include imprisonment, fines or a denial of insurance benefits. I understand all benefits are subject to conditions
stated in the Group Contract and coverage documents. If my plan is rescinded or canceled, I will receive from my insurer a notice at least
30 days prior to the effective date of the rescission explaining the reasons for the intended rescission and my right to appeal that decision to
the Commissioner of Insurance pursuant to subdivision (b) of Section 10273.4 of the California Insurance Code. Notwithstanding
subdivision (a) of Section 10273.4 or any other provision of the law, I understand that after 24 months following the issuance of my health
plan or insurance policy, my insurer may not rescind my health plan or insurance policy for any reason, and shall not cancel my health plan
or insurance policy, limit any provisions of the health plan or policy, or raise premiums due to any omissions, misrepresentations, or
inaccuracies in the application for, whether willful or not.
I understand that the preceding statements are subject to audit at any time and agree to provide CaliforniaChoice with any and all
information necessary to prove the above statements.
• My children’s dates of birth are accurate. My children are born to me or my spouse/domestic partner, or legally adopted, or a
non-temporary legal ward, and/or have an established parent-child relationship with me or my spouse/domestic partner. I understand that
I am required to notify CaliforniaChoice® when an established parent-child relationship ceases to exist.
12356
Who can be covered?
If all required documentation is received
before the 16th day of the month of
marriage, premiums are charged for the
full month and coverage begins on the
date of marriage.
If all required documentation is received
on or after the 16th day of the month of
marriage, coverage begins on the 1st of
the month following
the date of receipt.
Effective dates Requirements that MUST be met
■ New spouse must be legally married to the employee
■ New stepchild must also meet the dependent children requirements listed below
New Spouse/
New Stepchild
Birth/Adoption/
Legal Guardianship/
Eligible Dependent
Child
If birth/date of placement occurred
before the 16th of the month, coverage
begins on the first day of the month of
the date of birth/placement.
If birth/date of placement occurred on
the 16th or after, child is automatically
covered at no cost under Subscriber
between date of birth/placement and the
first of the following
month. Coverage for
the dependent begins on the first of the
month following the birth/date of
placement.
Domestic Partner/
Child of Domestic
Partner
During Initial Enrollment or Group’s
A
nnual Renewal:
Coverage begins on group’s effective
date.
Involuntary Loss of Other Coverage:
Domestic Partner can be added outside
of Renewal only if he/she loses other
coverage involuntarily. Coverage is
effective the first of following month.
Mid-Year Addition:
Mid-year additions of
a domestic partner will require a
state-stamped copy of the Certificate of
Registration of Domestic Partnership
from a state or local government agency
authorized to perform such registrations
within 60 days of issue or a signed
affidavit for opposite sex and over age
62 domestic partnerships. If all required
documentation is received before the
16th day of the month in which the
domestic partnership was established,
premiums are charged for the full month
and coverage begins on the date of the
event. If all required documentation is
received on or after the 16th day of the
month in which the domestic partnership
was established, coverage begins on the
1st of the month following
the date of
receipt.
For a Domestic Partner to qualify, Employee and Domestic Partner must:
■ Neither is married under either statutory, common law or part of another domestic
partnership
■ Both be 18 years of age or older; or, if under 18, have a valid court order allowing
partnership
■ Share an intimate and committed relationship
■ Agree to be jointly responsible for each other’s basic living expenses incurred during
the domestic relationship
■ Both be mentally competent
■ Not related by blood to a degree of closeness that would prohibit marriage in this
state
■ Agree to notify CaliforniaChoice® immediately upon termination of domestic
partnership
Children of Domestic Partner must also meet the dependent children requirements
listed above
Members who are in a same sex partnership, or the opposite sex and are over the
age of 62, are required to submit a state-stamped Certificate of Registration of
Domestic Partnership from a state or local government agency authorized to
perform such registrations within 60 days of issue; all others must submit a signed
A
ffidavit of Domestic Partnership.
(5 of 5) CC 0500D 12/2018 Eff. 4/1/2019
Family Coverage
Eligibility Requirements
721 South Parker, Suite 200, Orange, CA 92868
(
800
)
558-8003 www.calchoice.com
•
Dependents must meet all requirements listed in order to be
eligible for enrollment
MEDICAL, CHIRO, VISION and SMILESAVER DENTAL Dependent eligibility:
■ Born to, a stepchild or legal ward of, adopted by, or have an established parent-child
relationship with the eligible employee, employee spouse or domestic partner
■ Under age 26 (unless disabled, disability diagnosed prior to age 26)
AMERITAS DENTAL Dependent eligibility:
■ Born to, a stepchild or legal ward of, adopted by, or have an established parent-child
relationship with the eligible employee, employee spouse or domestic partner
■ Financially dependent upon the employee per IRS guidelines
■ Unmarried or not involved in a domestic partnership
■ Under age 26 (unless disabled, disability diagnosed prior to age 26)
Disabled Dependents:
Dependents who are incapable of self-support because of
continuous mental or physical disability that existed before the age limit are eligible
for coverage until the incapacity ends. Documentation of disability will be requested.
Once the child reaches the age limit for coverage, verification of eligibility will occur
annually at the child’s birthday.
Employee and Domestic Partner must meet all requirements
listed in order to be eligible for enrollment
12356
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Form 800: Change Request Form A Check here

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Completed 11 December 2020

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