Fillable enrollment/add/termination form (Town of East Longmeadow)

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enrollment/add/termination form (Town of East Longmeadow)

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CLEAR FORM
enrollment/add/termination form
PLEASE PRINT AND/OR TYPE INFORMATION. PRINT TO SIGN.
EMPLOYEE NAME (FIRST, LAST) COMPANY NAME PLAN
WILL ANYONE COVERED ON THIS POLICY KEEP OTHER HEALTH INSURANCE?
¨
YES
¨
NO
NAME OF INSURANCE CO. ________________________________ POLICY #________________________
NAMES OF COVERED INDIVIDUALS
___________________________________________________________________________
IS EMPLOYEE RETIRED?
¨
YES RETIREMENT DATE ______________________
¨
NO
ARE YOU OR ANY OF YOUR DEPENDENTS COVERED BY MEDICARE?*
¨
YES
¨
NO
IF YES,
¨
PART A
¨
PART B INCLUDE COPY OF MEDICARE CARD
MEDICARE CLAIM # _______________________________________________________________________
*If you have not indicated yes or no regarding your Medicare or other insurance status, you may receive a follow-up questionnaire.
FOR GROUP MEDICARE SUPPLEMENT MEMBERS: WILL THIS POLICY REPLACE ANY OTHER ACCIDENT
AND SICKNESS INSURANCE CURRENTLY IN FORCE?
¨
YES
¨
NO
PRIMARY CARE PROVIDER (PCP)
(REQUIRED FOR HMO PLANS)
(PCP) PROVIDER ID#
(REQUIRED FOR HMO PLANS)
IS THIS YOUR DOCTOR NOW?
¨
YES
¨
NO
SS# (REQUIRED)
DOB MONTH DAY YEAR
GENDER
¨
MALE
¨
FEMALE
ADDRESS STREET APT NO. P.O. BOX
CITY
STATE ZIP
TELEPHONE (HOME) TELEPHONE (WORK) EMAIL
( ) ( )
MARITAL STATUS:
¨
SINGLE
¨
MARRIED
¨
DIVORCED
¨
OTHER
PRIMARY LANGUAGE SPOKEN
ETHNICITY (use codes from back of form)
1ST 2ND
OTHER
RACE (Use codes from back of form)
DEPENDENT NAME(S)
FIRST LAST (IF NOT SAME AS EMPLOYEE)
ETHNICITY RACE LANGUAGE
DATE OF BIRTH
MO DAY YR
GENDER
M F
SOCIAL SECURITY # (REQUIRED) PCP NAME
(REQUIRED FOR HMO PLANS)
FIRST LAST
PROVIDER ID#
IS THIS YOUR
DOCTOR NOW?
Y N
(SEE REVERSE)
¨
SPOUSE
¨
OTHER
M F
M F
M F
M F
I UNDERSTAND THAT BY ACCEPTING COVERAGE UNDER THIS PLAN, HEALTH NEW ENGLAND AND
ANY HEALTH CARE PROVIDER MAY RECEIVE, USE AND DISCLOSE MY MEDICAL INFORMATION
FOR TREATMENT, PAYMENT, HEALTH CARE OPERATIONS, AND ANY AND ALL OTHER USES
ALLOWED BY LAW. I HAVE READ AND UNDERSTAND THE TERMS OF ENROLLMENT ON THE BACK
OF THIS FORM. I CERTIFY THAT ALL INFORMATION ON THIS FORM IS CORRECT AND COMPLETE
TO THE BEST OF MY KNOWLEDGE.
- -
- -
- -
- -
X
EMPLOYEE SIGNATURE DATE
X
- -
- -
- -
- -
One Monarch Place, Suite 1500
Springfield, MA 01144-1500
healthnewengland.org
Phone: (413) 787-4000 | (800) 842-4464 | Enrollment Fax (413) 233-2635
BELOW SECTION TO BE COMPLETED BY EMPLOYER
EFFECTIVE DATE ________________ (new enroll choose qualifying event below)
¨
TERM POLICY
¨
TERM DEPENDENT END DATE _____________________
¨
NEW ENROLLMENT
¨
ADD DEPENDENT
¨
CHANGE MEMBER INFO
CHOOSE REASON:
¨
NEW HIRE
¨
LOSS OF INSURANCE
¨
ANNUAL OE OTHER ________
(DATE OF HIRE REQUIRED) (SPECIFY)
CHOOSE REASON:
¨
LEFT EMPLOYMENT
¨
MOVED
¨
VOLUNTARY CANCEL
¨
COBRA TERM
¨
NO LONGER ELIGIBLE
¨
DECEASED
¨
TRANSFER TO COBRA
CHOOSE ONE:
¨
HNE COBRA
¨
HNE COBRA WITH HEALTH EQUITY HRA
TYPE OF COVERAGE:
¨
INDIVIDUAL
¨
FAMILY
¨
EE+1
¨
OTHER
DATE OF HIRE: _______________ HNE GROUP #:
—
TYPE OF PLAN:
¨
HMO
¨
PPO
¨
GROUP MEDICARE SUPPLEMENT
EMPLOYER SIGNATURE DATE
✔
Clear Form
SVRHT - East Longmeadow
✔
✔
S 0 3 0 4 2
0 0 1 A
RACE & ETHNICITY
Why are these questions being asked?
The Commonwealth of Massachusetts has established statewide goals for improving
health care quality and reducing racial and ethnic disparities in health care. HNE wants to
do our part to remove any barriers to fair and unbiased treatment for all of our members.
By collecting information about your race and ethnic background, we may be able to
identify possible issues that affect the care or treatment you receive. HNE will then be
able to work with our provider community to address any issues. We appreciate your
assistance in this effort.
This information is designed for the purpose of data collection and will not be used for
determining eligibility, rating or claim payment. HNE keeps this information confidential
according to our policies and state and federal law.
Code Description
2182-4 Cuban
2184-0 Dominican
2148-5 Mexican, Mexican American, Chicano
2180-8 Puerto Rican
2161-8 Salvadoran
2155-0 Central American (not otherwise specified)
2165-9 South American (not otherwise specified)
2060-2 African
2058-6 African American
AMERCN American
2028-9 Asian
2029-7 Asian Indian
BRAZIL Brazilian
2033-9 Cambodian
CVERDN Cape Verdean
CARIBI Caribbean Island
Code Description
2034-7 Chinese
2169-1
Colombian
2108-9 European
2036-2 Filipino
2157-6 Guatemalan
2071-9 Haitian
2158-4 Honduran
2039-6 Japanese
2040-4 Korean
2041-2 Laotian
2118-8 Middle Eastern
PORTUG Portuguese
RUSSIA Russian
EASTEU Eastern European
2047-9 Vietnamese
OTHER Other Ethnicity
UNKNOWN Unknown/not specified
IMPORTANT: PLEASE READ THESE
TERMS OF ENROLLMENT
As an employee, I understand that:
1. By submitting this form or accepting coverage under the plan, I agree,
on behalf of myself and all enrolled dependents, to abide by the terms
of the Health New England (HNE) Agreement, which includes this form
as well as the applicable Explanation of Coverage or Summary
Plan Description.
2. Membership will become effective upon acceptance by the Plan and
that benefits under the Plan will be explained in a separate
document (Explanation of Coverage or Summary Plan Description).
3. I may only enroll dependents subject to the guidelines outlined
in my HNE Agreement.
4. Whenever I seek treatment or services, I must identify myself as
an HNE member by presenting my HNE Identification Card.
5. I must select a Primary Care Physician for myself and my
dependents (does not apply to PPO).
6. If appropriate, I authorize my employer to deduct from my wages
the rate required for the coverage selected.
As an employer, I understand that:
1. By submitting this form, I certify that the information provided
on this form is accurate.
RACE Please choose from the following:
Fill in the code where indicated on the front of this form.
Code Description
R1 American Indian/Alaska Native
R2 Asian
R3 Black/African American
R4 Native Hawaiian or other
Pacific Islander
R5 White
R9 Other Race
UNKNOWN Unknown/not specified
ETHNIC GROUP Please choose from the following (you may choose more than
one). Fill in the code where indicated on the front of this form.
COM2298-0316-Interactive
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enrollmentaddtermination form (Town of East Longmeadow)

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Completed 3 August 2020

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