Healthy New York Member Enrollment Form printable pdf download

Healthy New York Member Enrollment Form

Mailing Address: Healthy New York Department, 14 Central Park Drive, Hookset, NH 03106 • 1-800-216-0778

THANK YOU FOR CHOOSING AN OXFORD PRODUCT

FOR YOU AND YOUR FAMILY.

IMPORTANT:

PLEASE PRINT AND PRESS DOWN FIRMLY WHEN COMPLETING THIS FORM.

IN ORDER TO PROCESS THE ATTACHED FORM AND BEGIN COVERAGE,

ALL FIELDS MUST BE COMPLETED ACCURATELY AND IN ITS ENTIRETY.

BE SURE TO:

Use only blue or black ballpoint pen

Enter all dates using the MM/DD/YYYY format

Employer and employee signatures are required

List any coordinating coverage (coverage in addition to this coverage)

List any coverage you had prior to this coverage

Attach disability paperwork, if applicable

Check “full-time student” in the child column if the child is between the ages of 19-26 and a full-time student at an accredited

institution

Check “young adult” in the child column if the child is under the age of 30, eligible, and enrolling onto the young adult option.

The young adult will also need to list their qualifying event, address and signature. Please note: The young adult option creates

a new right that allows a young adult or their parent to purchase health insurance through the parent’s group health insurance

policy if the young adult does not otherwise qualify as a dependent due to age. There is a separate premium for the young

adult option, which the young adult or the young adult’s parents must pay.

Submit this form within 31 days of the requested effective date or within 60 days of the qualifying event for COBRA or State

Continuation

IF YOU HAVE ANY QUESTIONS,

PLEASE FEEL FREE TO CALL CUSTOMER SERVICE AT

1-800-216-0778

OHP HNY MEF 1010

4524 R6

Healthy New York Member Enrollment Form