Fill and Sign the Medical Certificate of Fitness Template South Africa Form

New Jersey Small Employer – Member Enrollment/Change Request Form – OHP Oxford Health Plans (NJ), Inc. Mailing Address: P.O. Box 29142, Hot Springs, AR 71903 1-800-444-6222 www.oxfordhealth.com INSTRUCTIONS Employers – You must complete the Employer Group Information and sections A and J in order for this application to be processed. Employees – You must complete sections B through H and submit the signature of each Over-Age Child for which a Dependent Under 31 Continuation Election is made in accordance with Section I in order for this application to be processed. • Please PRINT except when a signature is requested. • If a dependent is disabled and you want to continue his or her coverage beyond age 26, you do not have to make a COBRA/NJSGC or Dependent Under 31 election. Instead, select “Other” in Section A3, and attach proof of disability. • For provider addresses, include the zip code plus the four digit extension (11 digits) • You can obtain the providers’ correct names and addresses from the appropriate provider directory. Qualifying Events COBRA and NJSGC C1. Termination of job or reduction in hours C2. Employee enrollment in Medicare (COBRA only) C3. Divorce (COBRA/NJSGC); civil union dissolution (NJSGC) C4. Death of employee C5. Loss of dependent child status under the plan C6. Disability (occurring subsequent to another qualifying event) Dependent Under 31 D1. Loss of dependent status and otherwise eligible D2. Reestablish eligibility: residency D3. Reestablish eligibility: nonresident full-time student D4. Reestablish eligibility: change in marital status D5. Reestablish eligibility: change in parental status D6. Reestablish eligibility: termination of other coverage CONDITIONS OF ENROLLMENT -- APPLICANT ACKNOWLEDGEMENTS AND AGREEMENTS On behalf of myself and the dependents listed in this Enrollment/Change Request form, I acknowledge that: 1. I authorize any physician or medical professional, hospital, clinic or other medical care institution, carrier, consumer reporting agency, and any employer to give Oxford Health Plans, Inc. or any consumer reporting agency acting on behalf of Oxford Health Plans, Inc., information pertaining to employment, other health coverage, and medical advice, treatment or supplies for any physical or mental condition relevant to me or a minor dependent applying for coverage. I agree that this authorization shall be valid for 30 months from the date I sign this Enrollment/Change Request form, unless revoked at an earlier date. 2. I agree that, if I revoke this authorization before it expires, such revocation shall not affect any action that Oxford Health Plans, Inc. has taken in reliance on the authorization. 3. I understand I may receive a copy of this authorization if I request one. 4. I agree Oxford Health Plans, Inc. will provide coverage in accordance with the terms of the contract for the group policy. 5. I agree that the provision of coverage and benefits is contingent upon payment of premiums and may be terminated in accordance with the terms of the group policy if premiums are not paid timely. I authorize my Employer to withhold payments from my wages as contribution to the premium, as appropriate. HINT Group Enrollment 1013 Group Information – To be completed by Employer: Group Name: Group Number: New Jersey Small Employer Member Enrollment/Change Request Form – OHP Contract Specific Package: 4. COVERAGE CONTINUATION 3. OTHER CHANGE 2. REMOVE 1. ADD Oxford Health Plans (NJ), Inc. Mailing Address: P.O. Box 29142, Hot Springs, AR 71903 1-800-444-6222 www.oxfordhealth.com A. Type of Activity – To be completed by Employer. Refer to instructions on cover before completing this form. Print clearly. Activity – Check all that apply Effective Date/ Date of Hire/Reason for Change Date of Event Enrollment of a new Subscriber _____/_____/_____ Date of Hire: _____/_____/_____ Add Spouse _____/_____/_____ ___________________________________________________ Civil Union Partner _____/_____/_____ ___________________________________________________ Add Domestic Partner _____/_____/_____ ___________________________________________________ Add Dependent Child _____/_____/_____ ___________________________________________________ Add Over-Age Child as a Dependent Under 31(and _____/_____/_____ ___________________________________________________ complete section A4) Employee Withdrawal/Termination _____/_____/_____ ___________________________________________________ Remove Spouse _____/_____/_____ ___________________________________________________ Civil Union Partner _____/_____/_____ ___________________________________________________ Remove Domestic Partner _____/_____/_____ ___________________________________________________ Remove Dependent Child _____/_____/_____ ___________________________________________________ Remove Over-Age Child as a Dependent Under 31 _____/_____/_____ ___________________________________________________ Name Change Change Plan Other Add/Change Office ID Numbers: Primary/OB/Gyn/ Dentist For Employee Total Disability* COBRA/NJSGC Length of Continuation (in months): 18 29 Date of Loss of Coverage: ___/___/___ Qualifying Event #:____________** Date of Qualifying Event: ___/___/___ *Attach proof of disability **Qualifying event #s: see list in Instructions. NJ-HINT-Group _____/_____/_____ _____/_____/_____ _____/_____/_____ _____/_____/_____ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ For Spouse/Civil Union Partner* Length of Continuation (in months): 18 36 Date of Loss of Coverage: ___/___/___ Qualifying Event #:________________** Date of Qualifying Event: ___/___/___ *Civil union partners are eligible to make an election pursuant to NJSGC, if applicable. 2 For Dependent or Over-age Child COBRA/NJSGC Length of Continuation (in months): 18 36 Loss of Coverage: ___/___/___ Qualifying Event #:__________________** Date: ___/___/___ Dependent Under 31 Qualifying Event #:__________________** OHP NJS MEF 6855 R11 Work Home B. Employee Information – To be completed by the Employee SSN: Street/Apt:_________________________________________________________________________________ City:___________________________________________________ State:_____ Zip Code: ______________ Birthdate (mm/dd/yyyy): Male Female Phone: (_____)________________ Employer Name:___________________________________________________________________________ Phone: (_____)__________________ Address:__________________________________________________________________________________ Employment Date: _____/_____/_____ City:___________________________________________________ State:_____ Zip Code: _____________ Hours worked per week:_________ Add Activity Name (Last, First, MI): Remove Continuation Other Change If a name change, indicate prior name: Primary Name____________________________________________________________ Provider #: Current Patient: Yes No Ob/Gyn Name____________________________________________________________ Provider #: Current Patient: Yes No Dentist Name____________________________________________________________ Provider #: Current Patient: Yes No Other Health Coverage? Yes No If yes: Other Rx Coverage? Yes No If yes: Payer Name: _____________________________________________________ Payer Name: _____________________________________________________ Policy #: ________________________________________ Policy #: ___________________________________________ Medicare ID#, if any: C. Plan Option – To be completed by the Employee Medicare ID#, if any: Small Group: NJ-HINT-Group Primary AdvantageSM (Liberty Network) 3 OHP NJS MEF 6855 R11 D. Other Individuals Covered – to be completed by the Employee. Identify individuals other than yourself for whom you are adding/changing/removing/continuing coverage. Attach additional pages if necessary, with your signature and dated. Attach proof of disability. 1. Spouse Domestic Partner 2. Child 3. Child 4. Child Civil Union Partner Add Remove Add Remove Add Remove Add Remove Other Continue Spouse Other Continue Other Continue Other Continue Continue CU Partner (NJSGC) Name (last, first, MI) Name (last, first, MI) Name (last, first, MI) Name (last, first, MI) L:____________________________ L:____________________________ L:____________________________ L:____________________________ F:____________________________ F:____________________________ F:____________________________ F:____________________________ MI:___________________________ Birthdate (mm/dd/yyyy): MI:___________________________ Birthdate (mm/dd/yyyy): MI:___________________________ Birthdate (mm/dd/yyyy): MI:___________________________ Birthdate (mm/dd/yyyy): Male Female / Disabled Male Female / Disabled Male Female / Disabled Male Female / Disabled Social Security Number: Social Security Number: Social Security Number: Social Security Number: Other Health Coverage Yes No If yes: Payer Name: ______________________________ Other Health Coverage Yes No If yes: Payer Name: ______________________________ Other Health Coverage Yes No If yes: Payer Name: ______________________________ Other Health Coverage Yes No If yes: Payer Name: ______________________________ Policy #: _______________________ Policy #: _______________________ Policy #: _______________________ Policy #: ______________________ Medicare ID #:___________________ Other Rx Coverage: Yes No If yes: Payer Name: ______________________________ Medicare ID #:___________________ Other Rx Coverage: Yes No If yes: Payer Name: ______________________________ Medicare ID #:___________________ Other Rx Coverage: Yes No If yes: Payer Name: ______________________________ Medicare ID #:__________________ Other Rx Coverage: Yes No If yes: Payer Name: ______________________________ Policy #:________________________ Policy #:________________________ Policy #:________________________ Policy #:_______________________ Medicare ID #:___________________ Medicare ID #:___________________ Medicare ID #:___________________ Medicare ID #:__________________ Continue on next page NJ-HINT-Group 4 OHP NJS MEF 6855 R11 1. Spouse, Domestic Partner, Civil Union Partner Primary Care Provider: Provider ID#:____________________ Primary Care Provider: Provider ID#:____________________ Primary Care Provider: Provider ID#:____________________ Primary Care Provider: Provider ID#:___________________ Current Patient? Yes No Ob/Gyn Office Provider ID#:____________________ Current Patient? Yes No Ob/Gyn Office Provider ID#:____________________ Current Patient? Yes No Ob/Gyn Office Provider ID#:____________________ Current Patient? Yes No Ob/Gyn Office Provider ID#:___________________ Current Patient? Yes No Dentist Office Provider ID #:___________________ Current Patient? Yes No Dentist Office Provider ID #:___________________ Current Patient? Yes No Dentist Office Provider ID #:___________________ Current Patient? Yes No Dentist Office Provider ID #:__________________ Current Patient? Current Patient? Yes No If last name is different from Employee’s, please explain: Current Patient? Yes No If last name is different from Employee’s, please explain: Current Patient? Yes No If last name is different from Employee’s, please explain: ______________________________ ______________________________ ______________________________ ______________________________ Living with Employee Yes No If NO, complete Section F ______________________________ Living with Employee Yes No If NO, complete Section F ______________________________ Living with Employee Yes No If NO, complete Section F Yes No Employed? Yes No If yes, complete Section E1 Home or billing address same as Employee? Yes No If NO, complete Section E2 2. Child E. Additional Spouse/Civil Union Partner/Domestic Partner Information – To be completed by Employee. If not applicable, please mark as “NA.” 3. Child 4. Child 1. Employer Name:_______________________________________________________________________ Employer Address:_____________________________________________________________________ City, State, Zip Code:___________________________________________________________________ Employer Phone: ( ) 2a. Street/Apt:_____________________________________________________________________________ 2b. Please explain why the address is different: _________________________________________ City, State, Zip Code:____________________________________________________________________ _________________________________________ NJ-HINT-Group 5 OHP NJS MEF 6855 R11 F. Additional Child Information – To be completed by Employee. Provide information below about children listed in Section D, if they have a different address from the employee. If multiple children are at an address, you may list them together. Attach additional pages as necessary, signed and dated. Name(s):_________________________________________________________ Name(s):________________________________________________________ Street/Apt:________________________________________________________ Street/Apt:_______________________________________________________ Street/Apt:________________________________________________________ Street/Apt:_______________________________________________________ City, State, Zip Code: _______________________________________________ City, State, Zip Code: ______________________________________________ Reason:_________________________________________________________ Reason:________________________________________________________ G. Race/Ethnicity – To be completed by the Employee, Choose a category that most closely describes you: at his/her option. NOTE: your response is appreciated American Indian or Alaskan Native Black, not of Hispanic origin Hispanic but NOT required! Asian or Pacific Islander White, not of Hispanic origin H. Employee Signature I represent that all the information supplied in this application is true and complete. I hereby agree to the Conditions of Enrollment set forth in this Enrollment/Change Request form. I authorize deductions from my earnings for any contributions required from me. Signature:_________________________________________________________________________Date: _____________________ I. Over-Age Child’s Signature I represent that all the information supplied in this application regarding the Dependent Under 31 Continuation Election is true and complete. I hereby agree to the Conditions of Enrollment set forth in this Enrollment/Change Request form. I hereby agree to make contributions required from me for the Dependent Under 31 Continuation Election. Signature:_________________________________________________________________________Date: _____________________ J. Employer Verification The requested activity is believed eligible and is approved by the Employer. If termination of coverage is requested, the Employer certifies that no employee contributions have been taken for any period subsequent to the requested termination date. Employer Representative: ____________________________________________________Date: _____________________________ Representative’s Title: _________________________________________________________ NJ-HINT-Group 6 OHP NJS MEF 6855 R11