Employee Enrollment Change Waiver Form, Lyons & Associates
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4FOR PLAN USE ONLY
Subscriber #:
Date:
4417 Corporation Lane
Virginia Beach, VA 23462
Optima Health Plan and Optima Health Insurance Company
Enrollment Application and Waiver 2-100
Coordination of Benefits
Optima Health Plan Selection:
Optima Health Insurance Company
Plan Selection:
Vantage (HMO)
POS
Vantage Direct
Equity Vantage
Equity POS
POS Direct
Plus (PPO)
Equity Plus
Design Vantage
Design POS
Equity Vantage Direct
Design Plus
Equity POS Direct
IMPORTANT:
•
Incomplete information will delay enrollment. Please complete all sections in blue or black ink.
•
Social Security numbers are to be provided for the primary subscriber, spouse and dependent child(ren) covered
by this plan.
•
If you are adding a spouse or dependent due to a qualified event, please attach supporting documentation.
A. GROUP INFORMATION
(Required to be completed by Employer)
New Applicant
ADD Dependent/Spouse
Address Change
Name Change
CANCEL ALL
Cancel Dependent/Spouse
COBRA
:
PCP Change
(effective date)
Group Name:
Group Number:
Subscriber Number:
Benefit Administrator Signature- Required
Status:
Hourly
Salary
Date Hired:
Effective Date of Coverage:
Coverage Cancellation Date:
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
(new hire waiting period must be satisfied)
B. EMPLOYEE INFORMATION
(PLEASE PRINT LEGAL NAME)
Last Name:
First Name:
Middle Initial:
Home Address:
City:
State:
Zip Code:
(no P.O. Box)
Social Security Number:
Date of Birth:
(mm/dd/yyyy)
Primary Phone:
Secondary Phone:
Gender:
Disabled:
Female
Male
Yes
No
Primary Care Physician: (PCP)
If applying for Optima Health Plan Health Maintenance Organization (HMO) or the Optima Health Point of Service Plan
(POS), please select a primary care physician from the Plan’s Provider Directory for each family member listed. The Optima
Health Preferred Provider Organization (PPO) and Optima Health Out-of-Area Preferred Provider Organization Plans (OOA)
do not require primary care selection.
PCP Last Name:
PCP First Name:
Provider Number:
Current Patient?
(If Known)
Yes
No
If you are 18 years of age or older, have you used tobacco regularly within the past 6 months (4 or more times
Yes
No
per week on average excluding religious or ceremonial uses)?
Are you currently enrolled or willing to enroll in a tobacco cessation wellness program?
Yes
No
Email Address:
I agree to accept electronic communications notifying me of important health plan information, including but not limited to,
the Certificate of Insurance, Electronic Explanation of Benefits, plan updates and Uniform Summary of Benefits documents.
By checking this box you agree to accept electronic communications.
SGAPP_2-100_COMBO_16
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