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Kaiser cal cobra form Cal-COBRA Information Sheet Explanation of California Continuation Benefits Replacement Act Cal-COBRA Important information regarding Cal-COBRA enrollment Cal-COBRA allows continued access to group health coverage for the following Please return your completed Cal-COBRA Enrollment Form that is enclosed with this packet to Kaiser Permanente by the date indicated on the attached letter. You may submit the enrollment via mail or fax. Simply follow the instructions on the enrollment form* Keep a copy for your records. If you need to make an appointment with your physician or need medical services let the receptionist or clerk know that you have applied for Cal-COBRA. 1. Former employees and their dependents of employers of 2-19 eligible employees and 2. Individuals who have exhausted continuation coverage under federal COBRA if they are entitled to less than 36 months of federal COBRA. Cal-COBRA coverage is available for up to 36 months to A subscriber and dependents who have exhausted continuation coverage under federal COBRA if they are entitled to less than 36 months of federal COBRA continuation coverage under both federal and state coverage will not exceed 36 months loses employment with the group through which he/ she enrolled for reason other than gross misconduct hours are reduced and he/she no longer qualifies for group coverage A dependent who loses group coverage due to divorce or legal separation A dependent losing group coverage due to the death of the subscriber A dependent child who marries or reaches the age limit for group membership or experiences a change in custody A dependent when a subscriber becomes entitled to Medicare. The effective date for your Cal-COBRA coverage is the date your group coverage ended* There can be no lapse in coverage. Monthly billing statements will be mailed to you. Do not enclose a payment with the enrollment form* Health Plan identification cards will be provided to new Members. A Member with an existing identification card will not be issued a new one. If we do not receive your entire dues payment on or before the last day of the month preceding the month of coverage we will send written notice of the termination to the Subscriber at least 15 days before the termination date. You are responsible for paying all Dues for the period prior to the termination effective date. If we receive full payment before membership* Also if we will terminate your membership for nonpayment of Dues we will reinstate your membership without a lapse in coverage if we receive full payment on or before the next scheduled payment due date following the one you missed* If you have any questions regarding Cal-COBRA coverage or would like information regarding State Continuation Coverage after Cal-COBRA or converting your membership to an individual plan please contact our Member Service Call Center at 1-800-464-4000. The federal Consolidated Omnibus Budget Reconciliation Act of 1985 COBRA requires employers of 20 or more employees except plans sponsored by the federal government and certain church related organizations to offer continuation of group coverage to employees and dependents who lose eligibility for group coverage.

Enrollment form carefirst Group Hospitalization and Medical Services, Inc. 840 First Street, NE Washington, DC 20065 Enrollment Form (Virginia Small Groups) HOW TO COMPLETE THIS FORM: 1. Please type or print clearly with pen.

Union point steam academy re e... Return form by 4/11/14 Union Point STEAM Academy REENROLLMENT FORM 20142015 School Year ReEnrollment Checklist ReEnrollment Form (signed & returned by 4/11/14) Childs Name (printed) Current Grade

Edi enrollment packet form The Part A/Part B/HHH EDI Enrollment packet contains forms and explanations for each of the services offered by our Electronic Data Interchange EDI department. Part A/Part B/HHH EDI Enrollment Packet Attention Please Read Before Completing Paperwork VA WV Part A Palmetto GBA has subcontracted with National Government Services NGS to continue EDI support of the Virginia and West Virginia Part A workload for Palmetto GBA. Please visit the eServices webpage at www. PalmettoGBA. com/eServices for function availability and registration information. To be eligible to participate in eServices you must have a completed an EDI Enrollment Agreement included in the packet that is actively on file with Palmetto GBA. If this recertification information is not verified and returned access will be terminated. Jurisdiction M EDI Enrollment Packet Individual Provider Corporate Office List all Medicare Provider Transaction and Access Numbers PTANs and National Provider Identifiers NPIs if Provide a list of individuals requiring access full name including middle initial is required before an ID can be assigned. Please visit contact the NGS Help Desk at 855-696-0705 for EDI support. Enrollment Submission We are now accepting completed enrollment paperwork via fax or email* EDI Part A 803-699-2429 EDIPartA. ENROLL Palmetto. GBA. com Email Enrollment Monitoring Your email address will be the primary method of communication with Palmetto GBA EDI Operations. We will send you a Tracking Number via email that you can use to monitor your enrollment process through the website at www. palmettogba*com/EDI. Be sure to include your email address on all EDI Enrollment forms. Please add palmettogba*com and bcbssc*com to your email contact list to ensure our emails are not filtered into your spam or junk mail folder. Take Control of your Accounts Receivable and Become Compliant Now Sign up today to receive your remittances electronically and be ahead of the game. Download and print your remits more quickly. CMS is focused on increasing the number of providers who receive their remittances electronically and decreasing the printing and mailing costs associated with hardcopy remittances. Complete your forms today Support We are committed to making your transition to EMC as smooth as possible. If you have any questions regarding the information contained in this package please feel free to contact the Palmetto GBA EDI Technology Support Center toll free at 855-696-0705. Thank you for your interest in Electronic Data Interchange Palmetto GBA PO Box 100145 Columbia SC 29202-3145 www. palmettogba*com A CMS Medicare Administrative Contractor Using Electronic Data Interchange Services administers the Part A Part B contracts for South Carolina North Carolina Virginia and West Virginia in addition to home health and hospice HHH services provided in the following states Alabama Arkansas Florida Georgia Illinois Indiana Kentucky Louisiana Mississippi New Mexico North Carolina Ohio Oklahoma South Carolina Tennessee and Texas.

Weatec enrollment form Weatec Enrollment Form (continued) I have talked with my Deacon about my need for internet access. Describe your need for internet access: I have read and understand ...

Term life amp disability enrol... Term Life Disability Enrollment Form Important notice This form replaces all other enrollment forms on file. Section 1 Member Information This enrollment is for Marriage New Member Death Open Enrollment Divorce Enrollment Change Please indicate the reason for change Date of change / Other Name Birth date Social Security Number Agency Employed Mailing Address City/State Sex Marital Status M F Home Phone Zip Work Phone Domestic Partner per Affidavit of Domestic Partnership Married Single Widowed Free 2 500 Member Term Life I request the following additional coverage check boxes that apply Member Term Life Dependent Term Life 17 000 new member and open enrollment 2 500 Spouse/Partner 2 500 each child 34 000 new member only Evidence of Insurability required for 5 000 spouse/partner life Member Additional Life Please list dependents being insured Date of Birth Annual Increase Option if qualified see brochure for limitations Relationship Increase Term Life to 41 000 48 000 55 000 62 000 and 69 000 Short Term Disability Insurance Check here to enroll Attach additional sheet if more space is required please enter current monthly salary new members Evidence of Insurability required any other time see brochure for limitations IMPORTANT To be eligible for Dependent Term Life Insurance and/or Short Term Disability Insurance you must be covered by Member Term Life Insurance. Beneficiary Designation The member may choose a beneficiary s to receive Term Life benefits. If no beneficiary survives payment will be made in accordance with the terms of the policy. Unless designated otherwise beneficiary designations for all Member Term Life coverage will be the same. For Dependent Term Life the member is the beneficiary. Primary Contingent Name of Beneficiary Address Signature and Authorization for Payroll Deduction and/or Beneficiary Designation I hereby apply for benefits under SEIU Local 503 OPEU group insurance plan issued by Regence Life and Health Insurance Company. I authorize my employer to deduct from my salary the amount necessary to cover my premium for the group coverage. The amount of such insurance and the premium thereon is subject to change as determined by the salary and age schedule as outlined in the benefit booklet and master policy issued by Regence Life and Health Insurance Company. Signature Please read the information on the back of this form* Date FOR PAYROLL USE ONLY MEMBER DATE CODE DEDUCTION AMOUNT Please keep a photocopy for your records and mail this original to SEIU Local 503 OPEU at P. O. Box 12159 Salem Oregon 97309 AGENCY EFFECTIVE DATE GWNN Revised 7/10 Application for Enrollment I request the insurance offered by Regence Life and Health Insurance Company and authorize my employer to deduct my premium from my pay. I understand that the insurance becomes effective the 1st of the month for which payroll deductions are taken* If payroll is on the 31st of the month the insurance will become effective the 1st of the following month and upon carrier approval* Payroll deduction may not be available through all employers contact your payroll department or the SEIU Local 503 OPEU benefits department if you have any questions. Benefit Eligibility You are eligible to apply for insurance if you are an active member of SEIU Local 503 OPEU and work at least 80 hours per month. Dependents eligible for coverage include spouse/partner and all unmarried dependent children under the age 19 or under age 26 if they are full time students. If enrolling a domestic partner attach a completed Affidavit of Domestic Partnership form or indicate on the front of this form that you have obtained a Certificate of Registered Domestic Partnership* If a dependent cannot perform the normal activities of a person of his or her age and sex on the date of his or her coverage would begin his or her coverage will not begin until he or she is so able. Termination of Coverage Coverage under the term life plan ends when the participant fails to make the required monthly premium payment and/or is no longer a member of SEIU Local 503 OPEU. If a plan participant retires or terminates employment term life insurance will be continued without cost for 31 days. Within that period you may convert your term life insurance to an individual permanent policy without medical examination* This individual policy will have an adjusted premium* Contact the SEIU Local 503 OPEU Benefits Department for an application* The plan may be amended from time to time or terminated in its entirety at any time by SEIU Local 503 Oregon Public Employees Union* PO Box 12159 Salem Oregon 97309-0159 503 581-1505 or 1-800-452-2146.

State of arizona flexible spen... STATE OF ARIZONA FLEXIBLE SPENDING ACCOUNTS OPEN ENROLLMENT FORM 2011 NEW EMPLOYEE TERMINATION PROCESS LEVEL SPECIAL ENROLLMENT QUALIFIED LIFE EVENT EFFECTIVE DATE RK REQUIRED DO NOT WRITE ABOVE THIS

Enrollment form 03nacfeb 2010 ENROLLMENT FORM Child's Name: (Last) (First) (Middle) (Nickname) Birthdate: / / Sex: Child Lives With: (Mother / Father / Both / Other) Enrollment Date: / / Address: City: Zip Code: FAMILY INFORMATION

65j 1833319 complete enrollmen... Complete FOR HCP TO COMPLETE AND SIGN 1.866.980.1066 Prescribers Information Treatment of Patient*: is given as a subcutaneous (SC) injection (This is not a prescription.) Please

Enrollment form therxhelpercom... Page 1 of 2 *PLEASE ONE PERSON PER APPLICATION* Please PRINT CLEARLY or you can access our fill-able application online by going to our website at www.therxhelper.com. Please mail application back

Aristada initio and aristada p... DIRECT PATIENT ENROLLMENT FORM Customer Service: (844) 8058884 Fax completed form to: (844) 8058885 *Indicates required field PATIENT INFORMATION PRIMARY PRESCRIPTION INSURANCE *Patient Name

Dupixent myway program enrollm... Enrollment Form Fax 18443879370 Phone 1844DUPIXENT 18443874936 Option 1 To prevent delays, complete all fields and FAX ALL 4 PAGES to number above. For additional assistance, call us at number above

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