Dental Membership Enrollment Form

Anthem
Dental Membership Enrollment Form
Dental Enrollment Department
PO Box 1193
Minneapolis MN 55440-1193
PART A – EMPLOYEE INFORMATION – Employee complete Parts A thru D and return form to benefit administrator.
Last
Employee’s
Name:
Gender:
Male
Female
First
Marital
Status:
Single
Married
Middle Initial
Widowed
Divorced
Legally Separated
Address
Employee’s
Address:
Social Security Number
/
/
Date of Birth (Month-Day-Year)
/
/
Home Phone Number
City
State
Work Phone Number
Zip Code
PART B – ENROLLMENT INFORMATION - Select Coverage Type (Check One Box Only):
Employee Only*
Family
Employee and Spouse
No Coverage * If waiving coverage for employee and/or any
Employee and Dependent Child(ren)
eligible family members, you must complete Part D.
PART C – DEPENDENT INFORMATION
Relationship
To Employee
First Name, Middle Initial, Last Name
(Include Last Name Only if Different From Employee’s)
Gender
Date of Birth
Month/Day/Year
Full Time
Student?
Unmarried?
Spouse
M
F
/
/
Dependent Child
M
F
/
/
Y
N
Y
N
Dependent Child
M
F
/
/
Y
N
Y
N
Dependent Child
M
F
/
/
Y
N
Y
N
PART D – EMPLOYEE SIGNATURE – Select One
Do you (the employee) have other dental coverage?
Yes
No Do your dependents have other dental coverage?
Yes
No
Name of Carrier: ___________________________________
Policy/Identification Number: ______________________________
I waive coverage for myself and/or my dependents and understand that by waiving coverage, whether entirely or partially paid by my
employer, that I waive the right to change this selection unless permitted in the group contract’s participation requirements and enrollment
restrictions. Anthem Blue Cross reserves the right to decline any further dental enrollment changes.
Employee Signature:
Date:
I am enrolling myself and/or my dependents and authorize payroll deductions, if applicable. I have read, or have had read to me, the
completed application and I realize that any false statement or misrepresentation in the application may result in a loss of coverage under
the policy. Refer to Note back of form for additional information. Employee Signature:
Date:
PART E – GROUP ENROLLMENT INFORMATION - THIS PART TO BE COMPLETED BY EMPLOYER
New Group
Hire Date: _______/________/________
Prior Coverage Start Date (if applicable): ________/________/________
Coverage Effective Date: ________/________/________
Existing Anthem Dental Group
Hire Date: _______/________/________
Prior Coverage Start Date (if applicable): ________/________/________
Coverage Effective Date: ________/________/________
New Hire – Apply Probationary Period (if
applicable) to determine Effective Date
Hire Date: __________ /______/_______
Effective Date:______ /_______/_______
Open Enrollment
Effective Date:
______ /_______/_______
Rehire Date Lay Off Began: ________/________/_______
Date Rehired: ________/________/_______
Return from Leave of Absence
Date Leave Began:
________/________/________
Date Returned to Work: ________/________/________
Employee Change Part Time to Full Time
Date of Status Change: ________ /________/________
Effective Date:
________ /________/________
Previously Waived Coverage or Loss of Coverage
Qualifying Event Reason:_________________________________
Hire Date: _____________ /_______/________
Event Date: ___________ /_______/________
Effective Date: ________ /_______/________
Group Name:
Group & Subgroup Numbers:
Group Representative’s Signature:
Date:
Phone Number: (
)
Anthem Blue Cross Life and Health Insurance Company is an independent licensee of the Blue Cross Association. ® ANTHEM is a registered trademark of
Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association.
09-04114.05
E801 CA 10.24.2013
Notes to Employee:
• California law prohibits an HIV test from being required or used by health insurance companies as a condition of
obtaining health insurance coverage.
• REQUIREMENT FOR BINDING ARBITRATION The following provision does not apply to class actions: IF YOU ARE
APPLYING FOR COVERAGE, PLEASE NOTE THAT ANTHEM BLUE CROSS AND ANTHEM BLUE CROSS LIFE AND
HEALTH INSURANCE COMPANY REQUIRE BINDING ARBITRATION TO SETTLE ALL DISPUTES INCLUDING BUT
NOT LIMITED TO DISPUTES RELATING TO THE DELIVERY OF SERVICE UNDER THE PLAN/POLICY OR ANY
OTHER ISSUES RELATED TO THE PLAN/POLICY AND CLAIMS OF MEDICAL MALPRACTICE, IF THE AMOUNT IN
DISPUTE EXCEEDS THE JURISDICTIONAL LIMIT OF SMALL CLAIMS COURT. It is understood that any dispute
including disputes relating to the delivery of services under the plan/policy or any other issues related to the plan/policy,
including any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract
were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by
submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as
California law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are
giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are
accepting the use of arbitration. THIS MEANS THAT YOU AND ANTHEM BLUE CROSS AND/OR ANTHEM BLUE
CROSS LIFE AND HEALTH INSURANCE COMPANY ARE WAIVING THE RIGHT TO A JURY TRIAL FOR BOTH
MEDICAL MALPRACTICE CLAIMS, AND ANY OTHER DISPUTES INCLUDING DISPUTES RELATING TO THE
DELIVERY OF SERVICE UNDER THE PLAN/POLICY OR ANY OTHER ISSUES RELATED TO THE PLAN/POLICY.
Employer Instructions
• Review Parts A, B, C, and D to be sure all information is complete, accurate and legible.
• For risk groups, please disregard Full-time Student and Unmarried sections in Part C. This information does
not need to be completed.
• When reporting effective dates use contractual start and stop guidelines as defined in your contract (i.e., first
of month, end of month, or actual dates).
Employer Complete Part: E - Group Enrollment Information
• Check one reason for enrollment and provide requested information including coverage effective dates.
• New Group – New customer initial employee enrollment. Complete the Prior Coverage Start Date if your
plan benefits include waiting periods and credit for prior creditable coverage applies.
• Existing Dental Group – Enrolling additional employees from an acquisition/merger who were not
previously offered/enrolled in your dental plan. Complete the Prior Coverage Start Date only if your plan
benefits include waiting periods and credit for prior creditable coverage applies.
• New Hire – Enroll newly hired employee. If a probationary period applies, the coverage effective date is
after the probationary period.
• Open Enrollment – An employee is enrolling during group’s open enrollment period.
• Rehire – A former employee was rehired.
• Return From Leave of Absence – An employee is returning from leave of absence.
• Employee Status Change – The employee’s employment status changed and the employee is now eligible
for dental benefits.
• Previously Waived Coverage or Loss of Coverage – If an employee waives coverage; he/she can only
enroll at a later date if the group contract includes an Open Enrollment period or if the individual has a loss
of other insurance coverage. If an employee or dependent involuntarily losses coverage and are now
eligible to enroll, complete this section.
• Group Name – Provide group name as listed in your contract.
• Group and Subgroup Number – Provide applicable numbers for individual employee.
• Group Representative – Sign, date, and provide your phone number.
Send Completed Forms To:
Anthem
Attn: Dental Enrollment Department
PO Box 1193
Minneapolis MN 55440-1193