Document 6498305

HOW TO ENROLL - COVENTRY “Kids Only” Plan
UTD MEMBER’S BENEFIT FOR 2011
• Complete Materials for the Coventry “Kids Only” coverage:
1. Coventry Enrollment Application – when completing the
application, list the child to be covered as the main subscriber
or employee. The UTD member’s information does not go on
this application. All questions should be answered based
upon only the child to be covered.
2. DOE-70 – complete this form with the UTD member’s
information.
• Submit the application for coverage:
1. By e-mail to [email protected]
2. Or by fax to (877) 559-7709
• Plan coverage and premium information can be downloaded
from the UTD web site (www.UTD.org)
If you have any questions please call or e-mail the UTDCoventry Enrollment Specialist, Marjorie Jerome, at (954) 3751578 or [email protected].
Enrollment Application
(for large group eligible employees)
Please PRINT to complete using black ink. Initial all corrections.
All questions must be answered.
Member Status Change
□ New Hire
□ Open Enrollment
If waiving coverage reason:
□ Special Enrollment*
□ Benefit change □ Additions □ Waiving coverage □COBRA*
*Complete Qualifying Event box below.
Effective Date of Coverage
Employer / Group Name
Employee Information
Social Security or HICN Number (required)
Sub-Group Number
Last Name
Benefits Admin Initials
First Name
M.I.
Height
Weight
Address
Apt.
City
State
Zip Code
Mailing Address (if different than above)
Apt.
City
State
Zip code
Home Telephone Number
Work Telephone Number
(
(
)
Language Preference
□ English □ Spanish □ Other
Date of Hire
E-Mail Address
Birth Date
Primary Care Physician (First and Last name)
Existing Patient? □ Yes (attach proof) □ No
Qualifying Event **include legal documentation
Event date:
□ Marriage**
□ Legal Guardianship**
.
□ Adoption**
□ Other
.
Insurance Co. Name:
Coventry Provider ID # (located in provider directory)
Dependent Child to age 30 Option
Do you want to cover eligible dependents to
age 30? □ Yes □ No
Other Health Coverage
When coverage with Coventry begins, will you or any dependents have any other health coverage?
Yes
Medicare Coverage
Do you or your covered dependents have Medicare coverage?
Medicare ID#:
Yes
Product Selection (required)
□ HMO
□ POS
□ PPO
.
.
.
#
#
#
No If “Yes”, please complete the following:
Insurance Co. Address:
Name(s)
Gender
□ Male □ Female
)
Insurance Co. Telephone #:
.
No If “Yes” please complete the following:
Medicare Part A effective date:
Medicare Part B effective date:
.
Please select one of the following reasons for Medicare coverage:
Age
Disability
ESRD
Other
Prior Health Coverage
Have you been covered by any other health coverage within the last 12 months (or 18 months for late enrollees)?
Yes
No (If yes, Certificates of Creditable Coverage will be requested.)
Family Information
For dependent coverage, list each dependent below. Indicate additional dependents on a separate sheet. Except for dependents pursuing a full-time or part-time student status at an
accredited institution, college, university, vocational or secondary school, dependents must maintain their primary residence in Coventry’s service area, or the dependent is not eligible for
HMO coverage. If dependent is unmarried and age 25, attach proof (a) if student: a letter from registrar’s office certifying current hours enrolled; or (b) if not a student but living in
household: proof of legal residence (driver’s license, etc); or (c) disabled: a physician’s certification stating date and degree of disability. The child until the end of the calendar year in
which the child turns 30, and meets the following requirements: (a) be unmarried and does not have a dependent of his/her own; (b) be a resident of Florida or a full-time or part-time
student; and (c) is not provided coverage as a named subscriber, insured, enrollee, or a covered person under any other group or individual health benefit plan or is not entitled to benefits
under Title XVIII of the Social Security Act.
***If a dependent who is eligible for coverage has a different last name than that of the employee, you must attach copies of supporting documentation showing evidence of his/her
dependent status (birth certificate, court order for guardianship, marriage certificate, etc.).
Social Security or HICN Number (required) Last Name
First Name
M.I. Height
Weight
1
2
3
4
Birth Date
Gender
Relationship to applicant
Primary Care Physician (First and Last Name)
□ Male
□ Spouse
□ Child Existing Patient?
□ Yes
□ No
□ Female
□ Dom Prt
□ Other
Social Security or HICN Number (required) Last Name
First Name
Birth Date
Gender
Relationship to applicant
Primary Care Physician (First and Last Name)
□ Male
□ Spouse
□ Child Existing Patient?
□ Yes
□ No
□ Female
□ Dom Prt
□ Other
Social Security or HICN Number (required) Dependent Last Name (if different***)
First Name
Birth Date
Gender
Relationship to applicant
Primary Care Physician (First and Last Name)
□ Male
□ Spouse
□ Child Existing Patient?
□ Yes
□ No
□ Female
□ Dom Prt
□ Other
Social Security or HICN Number (required) Dependent Last Name (if different***)
First Name
Birth Date
Gender
□ Male
□ Female
CHL.CHC.CHP.LG.EMP.APP (4/10)
Relationship to applicant
Primary Care Physician (First and Last Name)
□ Spouse
□ Child Existing Patient?
□ Yes
□ No
□ Dom Prt
□ Other
Coventry Provider ID # (located in provider directory)
M.I.
Height
Weight
Coventry Provider ID # (located in provider directory)
M.I.
Height
Weight
Coventry Provider ID # (located in provider directory)
M.I.
Height
Weight
Coventry Provider ID # (located in provider directory)
Coventry Health & Life Insurance Company, Coventry Health Care of Florida, Inc., Coventry Health Plan of Florida, Inc.
1340 Concord Terrace, Sunrise, FL 33323
Item# CHGF1599
Employees and dependents who are or become eligible for premium assistance under the Children’s Health Insurance Program (CHIP) or Medicaid or who lose coverage under CHIP or
Medicaid and are otherwise eligible for this plan may enroll in this plan within 60 days of the individual (or a dependent)losing eligibility for the Medicaid or CHIP program or within 60 days
of becoming eligible for premium assistance under Medicaid or CHIP even though the timing falls outside an open enrollment period and the employee previously refused employer
coverage.
Election of Coverage and Authorization
I, on behalf of myself and all dependents, authorize any licensed physician, medical practitioner, hospital, clinic, pharmacy, pharmacy benefits manager or other pharmacy related services
provider or other medical or medically related facility or provider, insurance company (including Coventry and affiliates), or other organization, institution or person, that has any records or
knowledge of the health of me or any dependent, including but not limited to personal information, records concerning physical or mental illness, information relating to autoimmune
deficiency syndrome (AIDS), human immunodeficiency virus (HIV), the use of drugs or alcohol or other advice, diagnosis, prognosis, prescription information, care or treatment provided to
me or any dependent, to release such information to Coventry or its authorized representatives. I, on behalf of myself and all dependents, hereby provide Coventry with consent to use
personally identifiable information for general treatment, underwriting, payment or health care operations, including but not limited to coordination of care, quality assessment, utilization
review, fraud detection or accreditation purposes. I understand information obtained with my authorization may be re-disclosed by Coventry as permitted or required by law and in some
instances may no longer qualify for protection under Federal and State privacy laws. I understand that my authorization is voluntary and that such information will be used by Coventry for
the purpose of evaluating my employer group’s application for health insurance. If personally identifiable information is to be used for any other purpose, Coventry will obtain specific
authorization from me and all other dependents as required by applicable law. This authorization is valid from the date signed until revoked by me in writing (which I may do at any time) or
such shorter period required by applicable law. Any revocation will not affect the activities of Coventry prior to the date revocation is received by Coventry.
I certify that all information and statements furnished by me are true and complete to the best of my knowledge. I understand that any misrepresentation or omission of any information
including pre-existing conditions may result in the rescission of my or any dependent’s coverage to the coverage effective date. I understand that I am financially liable for any charges
incurred after the effective date until the coverage is rescinded. I hereby acknowledge Coventry’s right to require proof of any dependent’s dependent status. I understand that Coventry
does not directly employ any participating providers or facilities. All health care providers and facilities are independent contractors and are not the agents or employees of Coventry. I
understand that I and all dependents must comply with the eligibility requirements as stated in the Certificate of Insurance/Certificate of Coverage, or Group Master Contract. The
Certificate of Insurance/Certificate of Coverage or “Certificate” can be obtained through (i) the website at www.CHCFlorida.com (ii) by contacting your Group Benefit Administrator, or (iii)
by calling the Customer Service Department; for Coventry at 1-866-847-8235 and requesting a hard copy of the Certificate be mailed via U.S. regular mail. Your signature on this
application represents acceptance of these delivery options.
I understand that any person who knowingly and with intent to injure, defraud, or deceive any insurer, files a statement of claim or an application containing any false,
incomplete or misleading information may be guilty of a felony of the third degree. Coventry may rescind coverage of any member who knowingly defrauds Coventry.
MY SIGNATURE CERTIFIES THAT I HAVE READ AND AGREE TO THE TERMS AND CONDITIONS OF THIS APPLICATION.
X
CHL.CHC.CHP.LG.EMP.APP (4/10)
Applicant Signature
Coventry Health & Life Insurance Company, Coventry Health Care of Florida, Inc., Coventry Health Plan of Florida, Inc.
1340 Concord Terrace, Sunrise, FL 33323
Date
Item# CHGF1599
DOE 70
Last Name
UTD MEMBER BENEFITS
First
M.I.
Work Location No.
Pay Code
Employee No.
Social Security Number xxx-xx________
Do not write in this box
FOR OFFICE USE ONLY!
DELETION
DEDUCTION CHANGE
NEW ACCOUNT
Number of Deductions:
___________
Total Amount Per Pay:
___________
Payroll Effective Date:
___________
I hereby give written authorization to the United Teachers of Dade to authorize the School Board of Dade
County to deduct by payroll deduction from my salary or to change the amount of the present deduction from
my salary, monies for various insurances provided by my union as indicated on this card and any other valid
authorization card still in effect. I understand the amount of the deduction could increase/decrease when I
authorize policy changes (endorsements) and/or the annual renewal of my policy.
I also authorize the UTD to discontinue all or any part of this deduction when the purpose therefore ceases to
exist.
I also agree to remain a dues-paying member of the United Teachers of Dade for the entire term of the
service(s) indicated on this card. Should I breach this agreement, payroll deduction will cease, and any
services(s) and/or insurance plan(s) rendered under this card will be terminated.
The School Board of Dade County shall be absolved from any and all liability resulting from the collection of
these funds.
_
REV. 10/27/2009
_______________ ____________________________________
Date
Signature
FOR OFFICE USE ONLY – PLEASE DO NOT WRITE BELOW THIS LINE!
INSURANCE
CODE
ADD
Number of Deductions: _________
INDICATE
(X)
DELETE
CHANGE
Total: _______________
TERM
OF
CONTRACT
ANNUAL
COST
AMOUNT PER
PAY
PERIOD
Payroll Effective Date: _______________