ENROLLMENT/CHANGE FORM ☐ New Enrollment	☐ Change	☐Termination

Effective Date:_______________________________________________ Reason for Change: ___________________________________________

EMPLOYER:
	SELECT ONE:
Certified	Classified	Admin
		
EMPLOYEE NAME:	Last, First, Middle:	E-mail Address:
	
ADDRESS:	Number & Street:	Apt. #:
	
City:	State:	Zip:	Phone:
	
Male Female
	HIRE/REHIRE DATE:
	DATE OF BIRTH:
	SOCIAL SEC.#1:
	CURRENT MARITAL STATUS
	IF STATUS CHANGE: Date of change
	
						single
married
		widowed
divorced

1Social Security numbers are required for all participants (employee and dependents) of the plan. This number will not appear on your ID card. CMS Reporting requires the plan to report this information to Medicare administration.

PLEASE COMPLETE ALL APPLICABLE BENEFIT SELECTIONS

Medical/Rx
		Single
Family
	
Dental
		Single
Family
	
Vision
		Single
Family

You will receive 2 cards at enrollment. If you need additional cards, check below:

2	4	6

DEPENDENTS TO BE ENROLLED
LAST NAME, FIRST NAME, MID INIT
	RELATIONSHIP3
	SEX
	BIRTH DATE
	SOCIAL SECURITY #1
	BENEFITS
	
Spouse:
		M	F
					M
V
		D
Rx

2Child:
		
M	F
				
							M
V
		D
Rx

2Child:
		
M	F
				
							M
V
		D
Rx

2Child:
		
M	F
				
							M
V
		D
Rx

2Proof of eligibility may be required.	3Relationship examples: Spouse, Son, Daughter, Stepchild, Adopted Child, Other (specify).

	 	PRIMARY CARE PHYSICIAN

MEMBER NAME
	
PCPFIRST &LAST NAME
	PHONE NUMBER (W/AREA CODE)
	STREET ADDRESS CITY,STATE,ZIP
	CURRENT PATIENT?
	
				Yes	No
	
				Yes	No
	
				Yes	No
	
				Yes	No

OTHER INSURANCE
		No members of my family are covered by any other plan of insurance.
The following members are covered by other insurance plans as noted below.

Policy Holder's Name:
	EMPLOYEE
	SPOUSE
	CHILD: ________________
	CHILD: ________________

Insurance Company:
					
Coverage Tier:
	SINGLE	FAMILY
	SINGLE	FAMILY
	SINGLE	FAMILY
	SINGLE	FAMILY

Coverage Type:
			MEDICAL
RX
		DENTAL
VISION
			MEDICAL
RX
		DENTAL
VISION
			MEDICAL
RX
		DENTAL
VISION
			MEDICAL
RX
		DENTAL
VISION

Authorization: I hereby certify that the information on this application is true and accurate to the best of my knowledge and belief. I realize that any material misstatement, misrepresentation or omission may be grounds for voiding or retroactive termination of coverage. I hereby authorize and direct any holder of medical information (including, but not limited to, diagnosis, treatment, advice, and prognosis) about me or any individual receiving coverage pursuant to my enrollment herein to provide such information to Mutual Health Services and/or Coordinated Health/Care. I hereby represent that I am the parent/legal guardian of all dependents enrolled hereby who are under 18 years of age and that I have the consent of each individual enrolled hereby who has attained the age of 18 to authorize the release of such information.

Signature of Employee _________________________________________________________

Signature of Employer _________________________________________________________

Date Signed _____________________________

Date Signed _____________________________

*** TO WAIVE ALL OR PART OF COVERAGE -- SEE REVERSE SIDE ***

COMPLETE THIS SECTION ONLY IF YOU WISH TO WAIVE PART OF THE COVERAGE OFFERED

Employee Name: _____________________________________________ Social Sec. Number ______________________________

Employer:

Waiver: I hereby certify that I have been given an opportunity to participate in the Employee Benefit Plan. The benefits of the plan have been thoroughly described to me, and I decline to participate. I understand that if, at a future date, I wish to apply for the benefits so waived, I may do so only as designated by the Plan Document.

Waiver of Coverage for:	Medical/Rx	Dental	Vision

Reason for Waiving: ______________________________________________________________________________

Signature of Employee _________________________________________________________	Date Signed ___________________________

NOTICE OF PRIVACY PRACTICES
WE CARE ABOUTYOURPRIVACY. THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUTYOU MAY BEUSEDAND DISCLOSEDAND HOW YOU CAN GET ACCESSTO THIS INFORMATION. PLEASE REVIEW CAREFULLY.

I. USESAND DISCLOSURES OF HEALTH INFORMATION
The plan may use identifiable health information about you for obtaining coverage and benefits under the Plan; directing and coordinating your treatment for covered services under the Plan; obtaining payment for treatment on your behalf; Treatment, Payment and Operations (“TPO”) of the Plan; Administrative purposes; Quality Assurance analysis including management of Coordinated Health/Care programs; and, evaluating the quality of care that you receive through the Plan.

The Plan may also use or disclose identifiable health information about you without your authorization for specific other reasons. The Plan provides information when otherwise required by law, such as for law enforcement in specific circumstances. Subject to certain requirements, we may give out identifiable health information without your authorization for public health purposes; abuse and neglect reporting; auditing purposes; research studies; funeral arrangements and organ donations; workers’ compensation purposes; and emergencies. The Plan may provide information to the Plan Sponsor (the Employer) for purposes of (i) underwriting the Plan; (ii) modifying or terminating the Plan; and (iii) plan quality assurance, management and administration functions.

In other situations, we will ask for your written authorization before using or disclosing any identifiable health information about you. If you choose to sign an authorization to disclose information, you can later revoke that authorization to stop any future uses and disclosures.

We may change our policies at any time. Before we make a significant change in our policies, we will change our notice and distribute the new notice in the manner employee communications are generally handled by the Employer. You may request a copy of our notice at any time. For more information about our privacy practices, contact the Human Resources office.

II. INDIVIDUAL RIGHTS
In most cases, you have the right to look at or get a copy of identifiable health information about you that we use in administering the Plan. If you request copies, we will charge you 5 cents for each page. You also have the right to receive a list of instances where we have disclosed identifiable health information about you for reasons other than treatment, payment or healthcare operations. If you believe that information in your record is incorrect or if important information is missing, you have the right to request that we correct the existing information or add the missing information.

You have the right to request that your identifiable health information be communicated to you in a confidential manner such as sending mail to an address other than your home. If this notice was sent to you electronically, you may obtain a paper copy of this notice.

You may request in writing that we not use or disclose information for treatment, payment or healthcare operations or to persons involved in your care except when specifically authorized by you, when required by law, or in emergency circumstances. The Plan will consider your request, but is not legally required to accept it.

III. COMPLAINTS
If you are concerned that your privacy rights have been violated, or you disagree with a decision we made about access to your records, you may contact the Human Resources office. You may also send a complaint to the U.S. Department of Health and Human Services. The Plan Administrator listed in the Plan Documents can provide you with the appropriate address upon request. Under no circumstances will you be retaliated against for filing a complaint.

IV. PLAN’S LEGAL DUTY
The Plan is required by law to protect the privacy of your information, provide this notice about our information practices and follow the information practices that are described in this notice. If you have any questions or complaints, you should contact the Plan Administrator listed in the Summary Plan Document that fully describes the Plan.