RETIREE ENROLLMENT FORM 2 MEDICAL ENROLLMENT TURN

CONTACT US:
916.874.2020 PHONE
916.874.4621 FAX
[email protected] EMAIL
http://www.personnel.saccounty.net/Benefits/Pages/default.aspx WEB
County of Sacramento, Employee Benefits Office
700 H Street, Room 4667, Sacramento, CA 95814
RETIREE ENROLLMENT FORM
1 RETIREE INFORMATION
Event _________________________________________________________________
Last Name
First Name
Physical Address
City
2
MEDICAL ENROLLMENT
NON-MEDICARE PLANS
Kaiser Permanente
Choose your
carrier:
Western Health Advantage
Sutter Health Plus
Choose your plan:
HMO
High Deductible
3
DENTAL COVERAGE
4
VISION COVERAGE
5
ENROLL Medical
State
Retiree Only
Date___________________________________
M.I.
Phone
Zip
Email Address
Retiree +1 Dependent
Retiree +2 or more Dependents
WAIVE Medical--Sign waiver acknowledgment on back
MEDICARE PLANS
Retiree Medicare Information
Medicare Claim Number _________--_______--___________
Kaiser Permanente
Silver
Gold
KPMP HOSPITAL (Part A) Effective Date
UHC Advantage HMO
HMO
NPPO
ENROLL Dental
Spouse Medicare Information
____ _________--_______--___________
MEDICAL (Part B) Effective Date
Do you have Medicare due to ESRD?
Retiree Only
Y
N
Does your spouse have Medicare due to ESRD?
Retiree +1 Dependent
Child
M
F
Last Name
ENROLL Vision
Retiree Only
Retiree +1 Dependent
Retiree +2 or more Dependents
WAIVE Vision--Sign waiver acknowledgment on back
Cover
DoB
Dr Name
Provider ID Number
Child
M
F
Last Name
First Name
Dr Name
Existing Patient
Y
DOB
Provider ID Number
First Name
Dr Name
DOB
Disabled?
Y
Provider ID Number
N
HMO
HDHP
Y
N
N
First Name
Dr Name
Existing Patient
SSN
DOB
Disabled?
Y
Provider ID Number
N
TURN OVER FOR AUTHORIZATION AND AGREEMENT, FORM NOT VALID UNLESS SIGNED BY RETIREE
Drop
Existing Patient Medical
Dental
Y N
Vision
Existing Patient
SSN
N
WAIVE Dental--Sign waiver acknowledgment on back
Retiree
Last Name
SP / DP
M
SSN
F
Y
Retiree +2 or more Dependents
ENROLLMENT INFORMATION
SSN
____
Y
N
Medical
Dental
Vision
KP Gold
KP Silver
Medical
Dental
Vision
Medical
Dental
Vision
OVER
UHC HMO
UHC NPPO
INSTRUCTIONS: If you are waiving coverage, initial the Waiver of Coverage section, then sign below at “X”. If you are enrolling in a new plan or
making a change to your current coverage, initial the arbitration agreement next to the plan you are enrolling in, then sign and date below at “X”.
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
WAIVER OF COVERAGE-I authorize the County of Sacramento to terminate my current County sponsored medical, dental and/or vision coverage prospective from
the date of the request. I understand that re-enrollment shall be contingent upon the Annuitant meeting the eligibility requirements as stated in the Retiree Health
Insurance Program Administrative Policy. Coverage shall end the last day of the month in which the request was made. ____________________ (initial, also sign at “X” below)
BINDING ARBITRATION-Health plan carriers handle and resolve member disputes through grievance, appeal and Independent Medical Review processes.
However, in the event that a dispute is not resolved in those processes the Plans use binding arbitration as the final method for resolving all such disputes. As a condition
of your membership in the Plan, you must initial next to your plan carrier to indicate that you understand and agree to the following:
WESTERN HEALTH ADVANTAGE (WHA) and SUTTER HEALTH PLUS (SHP)
A. On behalf of myself and my eligible Dependents, I hereby apply for health care coverage offered through my Employer, and agree to be bound by the Group
Service Agreement and Evidence of Coverage and Disclosure Form for the plan selected, 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 the Plan, 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.
WESTERN HEALTH ADVANTAGE--Retiree Initials: ______________ (also sign at “X” below)
SUTTER HEALTH PLUS--Retiree Initials: __________________ (also sign at “X” below)
KAISER PERMANENTE
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.
Retiree Initials: ________________ (also sign at “X” below)
AUTHORIZATION-All information on this form is true and correct; I understand 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 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. If applicable, I authorize the County to deduct from my pension the required premiums.
X RETIREE
SIGNATURE________________________________________________________
OFFICE USE ONLY MEDICARE SPLIT?
Y
N
Effective Date Of Change
Group Number
Date_________________________
Accepted By--Benefits Staff Representative:
Date