Fillable Employee Enrollment Form (Page 3 of 6) in pdf

Subscriber Last, First Name ______________________________________________

SSN____________________________________________

D. Prior Medical Insurance/Health Plan

This section must be completed to receive credit for prior medical

Coverage Information

insurance/health plan coverage.

Within the last 12 months, have you, your spouse/domestic partner, or your dependents had any other medical coverage?

YES (If YES, please complete this section and attach proof of coverage)

Prior medical carrier name____________________________________________________ Effective date ___/___/___ End date ___/___/___

Policy # (if applicable) _________________________________

Prior coverage type:

Employee

Spouse/Domestic Partner

Child(ren)

Family

Have you met any of your calendar year deductible?

Yes

No (If Yes, attach most current Explanation of Benefits/Explanation of Payment from the

previous insurance company/health care service plan.)

E. Other Medical Insurance/Health Plan

This section must be completed. (Attach sheet if necessary.)

Coverage Information

On the day this coverage begins, will you, your spouse/domestic partner or any of your dependents be covered under any other medical health plan or

policy, including another UnitedHealthcare plan or Medicare?

YES (continue completing this section)

NO (If NO, then skip this section.)

Name of other carrier ______________________________________________________ Other carrier policy#_______________________

Other Medical Insurance/Health Plan

Name and date of birth of policyholder/

Coverage Information

Type

Effective Date

End Date

covered employee for other insurance/

(only list those covered by other plan)

(B/S/F)

MM/DD/YY

health plan coverage



Employee:

Spouse/Domestic Partner Name:

Dependent Name:

B. Enter ‘B’ when this dependent is covered under both you and your spouse’s insurance/health plan coverage (married).



S. Enter ‘S’ if you are the parent awarded custody of this dependent and no other individual is required to pay for this dependent’s medical expenses.

F. Enter ‘F’ if this dependent is covered by another individual (not a member of your household) required to pay for this dependent’s medical expenses.

Medicare – Employee Information:

(If enrolled, please attach a copy of your Medicare ID card.)

Medicare ID# _________________________________________________

Enrolled in Part A: Effective Date _____________

Ineligible for Part A*

Not Enrolled in Part A (chose not to enroll)

Enrolled in Part B: Effective Date _____________

Ineligible for Part B*

Not Enrolled in Part B (chose not to enroll)

Enrolled in Part D: Effective Date _____________

Ineligible for Part D*

Not Enrolled in Part D (chose not to enroll)