Enrollment/change Form (Page 2 of 2) in pdf

Employee Name:_________________________________________

Group Name/ Group #:_________________________________

G. Medical

Coverage for

Employee Only Employee/Spouse Employee/Child(ren) Family

(Select one):

To enroll with CareConnect employees must live or work

Oscar plans are available to employees residing in

**Gated medical plan – Requires the selection of a PCP

in the following counties; Nassau, Suffolk, Manhattan,

the following NY counties: the Five Boroughs, Long

(complete Section H).

Brooklyn, Queens, Bronx, Richmond and Westchester

Island, Westchester and Rockland or NJ counties:

Require referrals to see specialists.

Middlesex, Union, Hudson, Essex, Morris, Passaic,

Bergen, Monmouth and Ocean.





CareConnect Standard Platinum EPO

Oscar Market Platinum EPO



Oxford Freedom Platinum EPO 5/15



CareConnect Value Platinum EPO

Oscar Simple Platinum EPO



Oxford Freedom Gold EPO 15/30



CareConnect Tradition Gold Copay EPO

Oscar Market Gold EPO

Oxford Liberty Gold EPO 30/60**





CareConnect Value Gold Copay EPO

Oscar Simple Gold EPO

Oxford Metro Gold EPO 25/40 NG



Oxford Metro Gold EPO 25/40**



Oxford Freedom Silver PPO 40/70



CareConnect Tradition Silver EPO 40/60 HRx





Oscar Market Silver EPO

Oxford Liberty Silver EPO 40/70



CareConnect Tradition Silver EPO HSA 100%



Oscar Simple Silver EPO

Oxford Liberty Silver EPO HSA 80%



CareConnect Value Silver EPO



Oxford Metro Silver EPO 30/60**



CareConnect Standard Bronze EPO

Oscar Market Bronze EPO



Oxford Metro Bronze EPO HSA 100%**



CareConnect Tradition Bronze EPO HSA 100%

Oscar Simple Bronze EPO

Employee ____________ Dependent 1 ____________ Dependent 2 ____________ Dependent 3 _____________

H. PCP Selection**

If enrolling in a gated medical plan** for the first time, you must select a primary care physician (PCP) for each member by listing the Provider ID # above.

If you do not select a PCP at initial enrollment one will be assigned. To change PCPs after initial enrollment you must contact the carrier directly.

I. Dental

Coverage for

): Employee Only Employee/Spouse Employee/Child(ren) Family

(Select one



Guardian Managed DentalGuard (DMO)***

Guardian Managed DentalGuard Plus (DMO)***

DentalGuard Plus

DentalGuard



Guardian DentalGuard Preferred (PPO)

Guardian DentalGuard Preferred Plus (PPO)

Solstice EPO

Solstice PPO

 







Solstice Dental EPO

Solstice Dental PPO

Employee ____________ Dependent 1 ____________ Dependent 2 ____________ Dependent 3 ____________

J. Dental Facility***

If enrolling in a DMO plan*** for the first time, you must select a Dental Facility ID # for each member by listing the Dental Facility # above. If you do not

select a facility at initial enrollment one will be assigned. To change the facility after initial enrollment you must contact the carrier directly.

K. Vision

Coverage for (Select one): Employee Only Employee/Spouse Employee/Child(ren) Family



VisionGuard

I choose to elect Guardian VisionGuard

Solstice Vision



I choose to elect Solstice Vision PPO

Indicate the percent of life insurance proceeds

L. Life/ADD/LTD

 EverGuard

 EverGuard Plus

Coverage type

(Select one):

for each beneficiary below (must total 100%).

Beneficiary Name 1*

Relation*

Percent*

Beneficiary Name 2*

Relation*

Percent*

M. ID Theft

Coverage for

 Employee Only  Family

(Select one):

PrivacyArmor

Coverage type

 PrivacyArmor

 PrivacyArmor Plus

(Select one):

Coverage for

 Employee Only  Employee/Spouse  Employee/Child(ren)  Family

(Select one):

Coverage type

 Benefit Elite

 Ultimate Plus



(Select one):

™  

LifeLock

A phone number is required when enrolling in either plan and a valid email address is required for LifeLock Ultimate Plus™

enrollment. Please include your preferred email in Section E. By submitting your enrollment in LifeLock service, you represent that you have the

authority to enroll those dependents indicated in LifeLock service and you have read and agreed to LifeLock’s Terms and Conditions which can be found at

https://

on behalf of yourself and on behalf of any member of your family you are enrolling.

N. Employee Signature

I hereby apply for the health insurance company and benefit plans selected, understanding all benefits and coverage as specified in the enrollment materials and agreeing to abide by all the rules and regulations therein specified. I certify that I

am actively at work a minimum of 20 hours per week and will notify HealthPass if my employment status changes. I elect to enroll myself and any family members indicated on this form with the benefit plans and primary care provider as

indicated on this form. I certify that all dependents listed on this form are eligible for coverage under the terms of the plan documents. I agree to notify my employer within 30 days when such eligibility ceases. I understand the plans have no

liability to provide coverage for ineligible dependents. On behalf of myself and all family members, I hereby authorize all physicians, nurses, hospitals and other providers who or which have at any time, either before or after we became covered

by the health insurance company, provided any diagnosis, treatment or any other service to any of us, to furnish the insurance companies or their authorized representative all information and records relating thereto. A photocopy or digital

image of this authorization shall be considered as valid as the original. I understand that the Participating Providers, if any, do not necessarily include all types of doctors or providers. I understand that if I am declining enrollment for myself or

my dependents (including my spouse) because of other health insurance coverage, I may in the future be able to enroll myself and my dependents, provided that I request enrollment within 30 days after the other applicable coverage ends.

(See HealthPass’ Eligibility Guidelines). In addition, if I have a new dependent as a result of marriage, birth, adoption, or placement for adoptions, I may be able to enroll myself and my dependents, provided that I request enrollment within 30

days after the marriage, birth, adoption or placement for adoption. If I am required to contribute premium toward my coverage, I hereby authorize my employer to deduct such contributions in advance from wages due to me and remit the same

to HealthPass. I understand that the subscriber is responsible for the total cost of care received and/or for drugs purchased which are not authorized by the plan. “Any person who knowingly and with intent to defraud any insurance company or

other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act,

which is a crime, and shall also be subject to civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation”. I have carefully read this section and certify that all information provided on this form is true

and complete to the best of my knowledge.

Employee Signature:

________________________________________________

Date:

___________________________

O. Authorized Signature

I certify that the person(s) presented on this form are eligible employees or dependents and the employee works for the employer identified on this form. This form and all other enrollment documentation submitted by the employer, or its duly

authorized officer, must be fully complete and transacted by the 20th of the month prior for effective coverage for the 1st of the following month. Any documentation received after the 20th of the month will result in delays in enrollment up to 10-

12 business days.

Authorized Signature:

________________________________________________

Date:

___________________________

HealthPass Group #: _________________