SPECIAL DISTRICT BENEFITS ENROLLMENT FORM TURN OVER

DISTRICT NAME
County of Sacramento, Employee Benefits Office
700 H Street, Room 4667, Sacramento, CA 95814
(916) 874-2020 Phone
(916) 874-4621 Fax
Email: [email protected]
SPECIAL DISTRICT BENEFITS ENROLLMENT FORM
Step 1-Employee Information
Employee Last Name
First Name
M.I.
SSN
DOB
Physical Address
City
ST
Zip
Date of Hire
Female
Male
Step 2-Choose your coverage
MEDICAL COVERAGE
SINGLE
HMO PLANS (Includes vision)
FAMILY
WAIVE MEDICAL
DENTAL COVERAGE
SINGLE
FAMILY
WAIVE DENTAL
VISION COVERAGE
SINGLE
FAMILY
WAIVE VISION
High Deductible HMO (no vision)
Kaiser $15 HMO
Kaiser HD HMO
WHA $15 HMO
WHA HD HMO
Sutter $15 HMO
Sutter HD HMO
Leave blank if enrolling in an HMO plan
Step 3-List List all family members and indicate the coverage they should have
Last Name:
You
First Name:
M.I.
SP / DP Last Name:
Cover
First Name:
Drop
Ch1
Last Name:
Cover
First Name:
Drop
Ch2
Cover
M.I.
M.I.
Last Name:
First Name:
Cover
M.I.
Last Name:
First Name:
M.I.
Last Name:
Cover First Name:
Drop
DOB:
F Group:
SSN:
M Dr:
DOB:
F Group:
SSN:
M Dr:
DOB:
Disabled?
Y
N
DOB:
DOB:
Disabled?
Y
N
DOB:
F Group:
M Dr:
Disabled?
Y
N
SSN:
M.I.
F Group:
M Dr:
SSN:
Drop
Ch4
M Dr:
SSN:
Drop
Ch3
SSN:
F Group:
M Dr:
Disabled?
Y
N
F Group:
Provider ID Number
Med Dental Vision Life
Existing Patient?
Y
Provider ID Number
N
Existing Patient?
Y
Provider ID Number
N
Existing Patient?
Y
Provider ID Number
N
Existing Patient?
Y
Provider ID Number
N
Existing Patient?
Y
Provider ID Number
N
Existing Patient?
N
Y
M
D
V
L
M
D
V
L
M
D
V
L
M
D
V
L
M
D
V
L
Step 4-Sign and date this form and return it to your District within 30 days of your hire of life event.
TURN OVER FOR AUTHORIZATION AND AGREEMENT, FORM NOT VALID UNLESS SIGNED BY EMPLOYEE
OVER
BINDING ARBITRATION By signing below, I acknowledge that I have read, understand and agree to the terms and arbitration agreement stated below. A reproduction of
this form shall be valid as an original.
WESTERN HEALTH ADVANTAGE:
A. On behalf of myself and my eligible Dependents, I hereby apply for health care services coverage offered by Western Health Advantage (WHA) through my
Employer, and agree to be bound by the WHA Group Service Agreement, Evidence of Coverage and Disclosure Form, and this Enrollment/Change Form.
B. 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.
Employee signature:____________________________________________________ Date:__________________________
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~
KAISER FOUNDATION HEALTH PLAN: I understand that (except for Small Claims Court cases, claims subject to a Medicare appeals procedure, and, if I am
enrolled in coverage that is subject to the ERISA claims procedure regulation, or any claims that cannot be subject to binding arbitration under governing law) 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.
Employee signature:___________________________________________________ Date:___________________________
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
SUTTER HEALTH PLUS (SHP) handles and resolves Member disputes through grievance, appeal and Independent Medical Review processes. However, in the
event that a dispute is not resolved in those processes, SHP uses binding arbitration as the final method for resolving all such disputes. As a condition of your
membership in Sutter Health Plus, you agree that any and all disputes between yourself (including any heirs or assigns) and Sutter Health Plus, 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 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. You and Sutter Health Plus, including
any heirs or assigns to this 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. _________________ (Initial)
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
AUTHORIZATION All information on this form is true and correct; I understand that it is the basis on which coverage may be issued under the plan(s). Any
dependents listed are my lawful spouse/domestic partner/and children, and are eligible for enrollment as my dependents. Any misstatements or omissions may result
in disciplinary action and/or future claims being denied and/or the policy being rescinded. My signature indicates my acceptance of the terms and conditions of the
evidence of coverage for the carrier I have selected including arbitration, benefit coverage, and all associated policies and procedures. If applicable, I authorize my
employer to deduct from my wages the required premiums.
Employee Signature___________________________________________________
OFFICE USE
ONLY
Rate Change? Effective Date Of Change
Y
N
Group Number
Date_____________________________
Accepted By--Benefits Staff Representative:
Date