New York Member Enrollment Form - Ohp printable pdf download

New York Member Enrollment Form - Ohp

New York Member enrollment Form – OHP

MAILING ADDRESS: P.O. Box 29142, Hot Springs, AR 71903 • 1-800-444-6222 •

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 19-23 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

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

1-800-444-6222

OHPNY MEF LS 1109 05-2013

333 REv 13

New York Member Enrollment Form - Ohp