CaliforniaChoice—Change Request Form (CC 0500)

Change Request Form
•
•
•
•
Use blue or black ink pen
Do not shrink this form
Do not use this form to change your physician or dentist
Fax completed form to (714) 558-8000 or
email to: [email protected]
• For assistance call (800) 558-8003
www.calchoice.com
Check here if changes are to be effective at Renewal
Complete steps A through E as applicable
A
Complete Employee Information
Employee Last Name
Employee Social Security Number
Employee First Name
Middle Initial
Check here if new address:
Residential Address
Mailing (Address changes will be effective the 1st day of the month following the receipt of the request)
Physical Address (Do not use P.O. Box for residential address)
State
Zip Code
County
Apt. #
Home Telephone
(
Name Change/Correction:
CaliforniaChoice ® Group #
City
Company Name
)
New First Name
New Last Name
B
Only Complete to Cancel Coverage or Add Dependents
Cancellations of coverage will take effect on the last day of the month after receipt of your request by CaliforniaChoice. Cancellations at Renewal will take effect on
the group’s Renewal date.
Additions (qualifying event): Please refer to administrative handbook for effective date guidelines based on qualifying event.
Additions (at renewal): Coverage will be effective on the group's renewal date.
This form must be received by CaliforniaChoice no later than 60 days after the event takes place if outside renewal.
IF APPLICABLE:
Date of marriage*/divorce if
adding/cancelling spouse:
If child custody*, enter
date of adoption:
*Attach copy of marriage license and/or certificate as applicable
Employee
Coverage Type
Reason for
Cancellation:
*Attach copy of legal documentation
Spouse/Domestic Partner
Child
Child
Child
❑ Cancel
❑ Add ❑ Cancel
❑ Add ❑ Cancel
❑ Add ❑ Cancel
❑ Add ❑ Cancel
❑ Medical
❑ Dental
❑ Voluntary Vision
❑ Medical
❑ Dental
❑ Voluntary Vision
❑ Medical
❑ Dental
❑ Voluntary Vision
❑ Medical
❑ Dental
❑ Voluntary Vision
❑ Medical
❑ Dental
❑ Voluntary Vision
Last Name
First Name
Social Security # required!
Social Security No.
❑ Male
Gender
❑ Female
Social Security # required!
❑ Male
❑ Female
Social Security # required!
❑ Male
❑ Female
Social Security # required!
❑ Male
❑ Female
Date of Birth
Disabled?
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
Primary Care Physician*
Current Patient?
❑ Yes ❑ No
❑ Yes ❑ No
Physician ID#
Physician City
❑ Check here if you would like your Health Plan to assign you a Primary Care Physician.
To enroll more dependents, complete sections A & B on an additional Change Request Form.
* If changing health plans or adding a plan, please select a Primary Care Physician. A Primary Care Physician (PCP) is not required for Kaiser Permanente,
EPO and PPO benefit plans. If a PCP is not contracted with your selected Health Plan prior to enrolling or if a PCP is not listed, one will automatically be
assigned to you. For PCP changes only, please contact your Health Plan directly.
(1 of 5)
PLEASE READ & SIGN THE BACK OF THIS FORM!
CC 0500 12/2013
Employee Name
Group Number
IF ADDING DEPENDENT(S) ON PAGE 1: By signing this document I declare under the penalty of perjury under the laws of the state of California that
the following statements are true and correct regarding the enrolling dependents listed on page 1, as applicable:
My spouse and I are legally married as recognized by the state of California.
My children's dates of birth are accurate. My children are born to me or my spouse/domestic partner, or legally adopted, or a non-temporary legal ward, and/or
have an established parent-child relationship with me or my spouse/domestic partner.
I understand that I may be asked for legal proof of the above at any time.
I understand that false statements and/or failure to provide the information upon request will cause the termination of all CaliforniaChoice benefits 15 days
following the date of the notice of termination and I will be held responsible for all services and charges incurred through CaliforniaChoice program providers
thereafter.
I understand that any persons, business, or health plan that suffers a loss because of false declarations contained in this statement may have cause to bring
civil action against me to recover their losses.
The representations made are the basis upon which coverage may be issued. If any Material fact was omitted or misrepresented, the coverage may be cancelled
or the employer’s contract rescinded.
I have READ, UNDERSTAND and ATTEST that I myself and my dependents have met all of the eligibility requirements.
IMPORTANT: Regarding Steps C and D, plan changes are only allowed at Renewal. However, employees who
acquire a new dependent (i.e. newborn, new spouse etc.) are able to change their coverage outside of the Renewal
Period.
C
Only Complete to Add/Change your benefit plan
(CHECK ONE)
❑ ADD
❑ CHANGE
IMPORTANT: Please select ONE benefit plan from the metal tier(s) shown on your Enrollment Worksheet.
HMO / EPO / PPO
HEALTH PLAN
BRONZE
AETNA
SILVER
■ HMO A
■ HMO A
■ HMO B
■ EPO A
■ HMO A
ANTHEM BLUE CROSS
■ EPO A
GOLD
PLATINUM
■ HMO A
■ HMO B
■ PPO A
■ PPO B
■ HMO A
■ HMO A
■ HMO B
■ PPO A
■ PPO B
■ PPO C
■ PPO D
■ HMO A
■ PPO A
■ HMO A
■ PPO A
■ PPO A
■ HMO A
■ HMO B
■ HMO A*
■ HMO B
■ HMO C*
■ HMO A*
■ HMO B
■ HMO C
■ HMO A
■ HMO B
■ HMO A
KAISER PERMANENTE
SHARP
■ HMO A
■ HMO B*
■ HMO A
■ HMO B
■ HMO A
■ HMO B
■ HMO A
■ HMO B
WESTERN HEALTH ADVANTAGE
■ HMO A*
■ HMO A
■ HMO A
■ HMO A
HEALTH NET
*HSA Qualified High Deductible Plan
D
Only Complete to Add/Change Optional Benefits
Dental Benefit Design Change/Add
(CHECK ONE)
❑ ADD
❑ CHANGE
❑ FDH 100
❑ Prepaid 1000†
❑ Prepaid 3000†
❑ Voluntary Prepaid 3000†
If electing any plan above, please select a dentist
ID #
Dentist’s Name (If left blank or dentist unavailable, one will be assigned)
❑ EPO 3000
❑ EPO 3500
❑ PPO 4000
❑ PPO 5000
†
❑
Check if
current dentist
Voluntary Vision Add
❑ Check this box to add Voluntary Vision (at additional cost)
(continued on next page)
(2 of 5)
CC 0500A 12/2013
Employee Name
Group Number
Life Insurance Beneficiary Change
Complete only if you wish to change the existing beneficiary on your life insurance. This change will take effect on the date it was signed.
I hereby revoke any previous designation of beneficiary and settlement provisions and make the following beneficiary designation
with respect to any insurance payable at my death under the group plan (including any Group Life Insurance or Group Accidental
Death and Dismemberment Insurance):
Beneficiary Name(s):
Last Name
First Name
Date
of
Birth
Relationship to You
M.I. (Mo/Day/Yr) (i.e. spouse, friend, child)
*Type of
Beneficiary
*Percentage
❑
❑
❑
❑
❑
❑
*
E
Primary
Contingent
Primary
Contingent
Primary
Contingent
If you are listing more than one primary beneficiary or more than one contingent beneficiary, please enter the percentage of the insurance
proceeds that each individual should receive. The percentage of insurance proceeds must equal 100% for each type of beneficiary (primary or
contingent). No contingent beneficiaries will be entitled to any part of the insurance proceeds if any primary beneficiary is living at the time of
death of the insured.
Complete Your Legal Acknowledgement - Read, Sign and Date Where Indicated
By submitting this signed application, I agree and understand that the health plan I have chosen through the CaliforniaChoice® program shall automatically have
a lien on any payment of monies from any source, for services rendered in conjunction with an injury caused by the acts or omissions of a third party.
I agree for myself and my dependents to be bound by the benefits, copays, deductibles, exclusions, limitations and other terms of the health plan’s small group
contract.
I authorize my physician, healthcare provider, hospital, clinic or other medically related facility to furnish my, and my dependent’s, protected health information,
including medical records, to the health plan I have chosen through the CaliforniaChoice program or its authorized agents for the purpose of review, investigation,
or evaluation of an application or claim, and for quality assurance and utilization review. I authorize CaliforniaChoice and the health plan I have chosen, and their
agents, designees or representatives, to disclose to a hospital, health plan, insurer or healthcare provider any protected health information if such disclosure is
necessary to allow the performance of any of those activities. This authorization shall become effective immediately and shall remain in effect for up to 30 months
from the date the authorization was signed. I understand that I, or a person authorized to act on my behalf, is entitled to receive a copy of this authorization form.
I have read and understand the information provided to me pertaining to the Premium Only Plans and the tax consequences.
I declare under the penalty of perjury under the laws of the state of California that the following statements are true, correct and pertain to the employer
named on this application, myself and my dependents named on this application.
• I am either actively, permanently working for the employer and considered eligible by my employer because I work either 20+ or 30+ hours per week, or I
am an eligible COBRA/Cal-COBRA participant.
• I am not a temporary, seasonal, per diem, 1099 or substitute employee or insured by or eligible to be insured by the employer’s union policy.
• My children’s dates of birth are accurate. My children are born to me or my spouse/domestic partner, or legally adopted, or a non-temporary legal ward, and/or
have an established parent-child relationship with me or my spouse/domestic partner. I understand that I am required to notify CaliforniaChoice when an
established parent-child relationship ceases to exist.
I understand that the above statements are subject to audit at any time and agree to provide CaliforniaChoice with any and all information necessary to prove the
above statements.
I understand that false statements and/or failure to provide the information upon request will cause the termination of all CaliforniaChoice benefits 15 days
following the date of the notice of termination and I will be held responsible for all services and charges incurred through CaliforniaChoice program providers
thereafter.
I understand that any persons, business or health plan that suffers a loss because of false-declarations contained in this statement may take legal action against
me to recover their losses.
• The representations made are the basis upon which coverage may be issued.
• If any Material fact was omitted or misrepresented, the coverage may be cancelled or the employer’s contract rescinded.
• I have READ, UNDERSTAND and ATTEST that I myself and my dependents have met all of the eligibility requirements listed on page 5 of this application.
California law prohibits an HIV test from being required or used by health care service plans as a condition of obtaining coverage.
(continued on next page)
(3 of 5)
CC 0500B 12/2013
E
(Continued) Complete Your Legal Acknowledgement - Read, Sign and Date Where Indicated
AETNA
ENROLLEES:
Notice of Binding
Arbitration:
Any dispute arising
from or related
to Health Plan
Membership will be
determined by submission to binding
arbitration, and not
by a lawsuit or
resort to court
process except as
California Law provides for judicial
review of arbitration
proceedings. The
agreement to arbitrate includes, but is
not limited to, disputes
involving
alleged professional
liability or medical
malpractice, that is,
whether any medical
services covered by
this agreement were
unnecessary
or
were unauthorized
or were improperly,
negligently
or
incompetently rendered. The health
plan agreement also
limits certain remedies and may limit
the award of punitive damages. See
the Evidence of
Coverage for further
information.
I
understand that I
am giving up the
constitutional right
to have disputes
decided in a court of
law before a jury,
and instead am
accepting the use of
binding arbitration.
This means that
members will not be
able to try their case
in court. I further
understand that the
agreement contains
limitations on certain remedies and
that there may be
certain limitations to
the recovery of
punitive damages.
Employee SIGN HERE:
ANTHEM BLUE CROSS
ENROLLEES:
I understand that if my coverage is
provided pursuant to an employersponsored benefit plan that is
exempt from Employee Retirement
Income Security Act of 1974
(ERISA) or if I have a dispute that is
not governed by ERISA that I will be
subject to the following binding
arbitration provision.
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.
HEALTH NET
ENROLLEES:
BINDING ARBITRATION
AGREEMENT:
Subject to the terms of
the Plan Contract or
Insurance Policy (which
may prohibit mandatory
arbitration of certain disputes if the Plan Contract
or Insurance Policy is
subject to ERISA, 29
U.S.C. section 1001, et
seq.), I, the Employee,
understand and agree that
any and all disputes or
disagreements between
me (including any of my
enrolled family members
or heirs or personal representatives) and the Health
Net Entities regarding the
construction, interpretation, performance or
breach of the Plan
Contract or Insurance
Policy, or regarding other
matters relating to or arising out of my Health Net
Entities
membership,
whether stated in tort,
contract or otherwise, and
whether or not other parties such as health care
providers, or their agents
or employees, are also
involved, must be submitted to final and binding
arbitration in lieu of a jury
or court trial. I understand
that, by agreeing to submit all disputes to final
and binding arbitration, all
parties, including the
Health Net Entities, are
giving up their constitutional right to have their
dispute decided in a court
of law before a jury. I also
understand that disputes
that I may have with the
Health Net Entities involving claims for medical
malpractice are also subject to final and binding
arbitration.
A
more
detailed arbitration provision is included in the Plan
Contract or Insurance
Policy.
My signature
below indicates that I
agree to submit any dispute to binding arbitration.
Print Name
KAISER
FOUNDATION
HEALTH PLAN
ENROLLEES:
Arbitration
Agreement:
I understand that
(except for Small
Claims Court cases,
claims subject to a
Medicare
appeals
procedure, and, if I
am enrolled in a
group that is subject
to ERISA, certain benefit-related disputes)
any dispute between
myself, my heirs, relatives, or other associated parties on the
one hand and Kaiser
Foundation
Health
Plan, Inc. (KFHP), any
contracted health care
providers, administrators, or other associated parties on the
other
hand,
for
alleged violation of
any duty arising out of
or related to membership in KFHP, including any claim for
medical or hospital
malpractice (a claim
that medical services
were unnecessary or
unauthorized or were
improperly, negligently, or incompetently
rendered), for premises liability, or relating
to the coverage for, or
delivery of, services
or items, irrespective
of legal theory, must
be decided by binding
arbitration
under
California law and not
by lawsuit or resort to
court process, except
as applicable law provides for judicial
review of arbitration
proceedings. I agree
to give up our right to
a jury trial and accept
the use of binding
arbitration. I understand that the full
arbitration provision
is contained in the
Evidence of Coverage.
SHARP
ENROLLEES:
It is understood that any
dispute
or
controversy
between the
Member and
the Plan arising out of or in
connection
with
this
G r o u p
Agreement,
excluding a
claim of medical malpractice, will be
determined by
submission to
final and binding arbitration
in accordance
with the provisions
of
Article XIII of
this
Group
Agreement,
and not by
a lawsuit or
resort to court
p r o c e s s
except
as
California law
provides for
judicial review
of arbitration
proceedings.
Both parties
to this Group
Agreement, by
entering into
it, are giving
up their constitutional
right to have
any such dispute or controversy
decided in a
court of law
before a jury,
and instead
are accepting
the use of
arbitration.
WESTERN
HEALTH
ADVANTAGE
ENROLLEES:
Arbitration
Agreement:
I agree and
understand that
any and all disputes between
myself (including
any heirs or
assigns)
and
Western Health
Advantage,
including claims
of medical malpractice (that is
as to whether any
medical services
rendered under
the health plan
were unnecessary or unauthorized or were
improperly, negligently or incompetently
rendered), except for
Small
Claims
Court cases and
claims subject to
ERISA, shall be
determined by
submission to
binding arbitration. Any such
dispute will not
be resolved by a
lawsuit or resort
to court process,
except
as
California
law
provides for judicial review of
arbitration proceedings.
The
parties, including
any heirs or
assigns, to this
arbitration agreement 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 binding arbitration.
Date:
My signature acknowledges both the applicable arbitration disclosure of the health plan I indicated in Section C and my decision to enroll in and/or
cancel the medical, dental, vision or life coverage that I indicated in Sections C and D.
(4 of 5)
CC 0500C 12/2013
Family Coverage Eligibility Requirements
Who can be covered? Effective dates
New Spouse/
New Stepchild
If marriage occurred before the 16th of
the month, coverage begins on the first
day of the month of the date of marriage.
Requirements that MUST be met:
■ New spouse must be legally married to the employee
■ New stepchild must also meet the dependent children requirements listed below
If marriage occurred on the 16th of the
month or after, coverage begins on the
first of month following date of marriage.
Birth/Adoption/
Legal Guardianship/
Eligible Dependent
Child
If birth/date of placement occurred
before the 16th of the month, coverage
begins on the first day of the month of
the date of birth/placement.
MEDICAL, CHIRO, VISION and SMILESAVER DENTAL Dependent eligibility:
■ Born to, a stepchild or legal ward of, adopted by, or have an established parent-child relationship with the eligible
employee, employee spouse or domestic partner
■ Under age 26 (unless disabled, disability diagnosed prior to age 26)
If birth/date of placement occurred on
the 16th or after, child is automatically
covered at no cost under Subscriber
between date of birth/placement and the
first of the following month. Coverage for
the dependent begins on the first of the
month following the birth/date of
placement.
AMERITAS DENTAL Dependent eligibility:
■ Born to, a stepchild or legal ward of, adopted by, or have an established parent-child relationship with the eligible
employee, employee spouse or domestic partner
■ Financially dependent upon the employee per IRS guidelines
■ Unmarried or not involved in a domestic partnership
■ Under age 26 (unless disabled, disability diagnosed prior to age 26)
Disabled Dependents: Dependents who are incapable of self-support because of continuous mental or physical disability that
existed before the age limit are eligible for coverage until the incapacity ends. Documentation of disability will be requested.
Once the child reaches the age limit for coverage, verification of eligibility will occur annually at the child’s birthday.
Dependents must meet all requirements listed in order to be eligible for enrollment
Domestic Partner/
Child of Domestic
Partner
(5 of 5)
During Initial Enrollment or Group’s Annual
Renewal:
Coverage begins on group’s effective date.
Involuntary Loss of Other Coverage:
Domestic Partner can be added outside of
Renewal only if he/she loses other coverage
involuntarily. Coverage is effective the first of
following month.
Mid-Year Addition: Mid-year additions of a
domestic partner will require a state-stamped
copy of the Certificate of Registration of
Domestic Partnership from a state or local
government agency authorized to perform
such registrations within 60 days of issue or
a signed affidavit for opposite sex and under
age 62 domestic partnerships. If domestic
partnership established before the 16th of
the month, coverage begins on the first day
of the month of the date of event. If domestic
partnership established on the 16th of the
month or after, coverage begins on the first
of month following date of event.
For a Domestic Partner to qualify, Employee and Domestic Partner must:
■ Share a common residence
■ Neither is married under either statutory, common law or part of another domestic partnership
■ Both be 18 years of age or older
■ Share an intimate and committed relationship
■ Agree to be jointly responsible for each other’s basic living expenses incurred during the domestic relationship
■ Both be mentally competent
■ Not related by blood to a degree of closeness that would prohibit marriage in this state
■ Agree to notify CaliforniaChoice ® immediately upon termination of domestic partnership
Children of Domestic Partner must also meet the dependent children requirements listed above
Members who are in a same sex partnership or are over the age of 62 are required to submit a state-stamped
Certificate of Registration of Domestic Partnership from a state or local government agency authorized to perform
such registrations within 60 days of issue; all others must submit a signed Affidavit of Domestic Partnership.
Employee and Domestic Partner must meet all requirements listed in
order to be eligible for enrollment
CC 0500D 12/2013