Group Health Employee Application/Change Form Please forward to: FHCP Enrollment Dept.
EMPLOYER USE ONLY: Group No: _______________ Employer: ________________________________________________ Phone: _____________________
1340 Ridgewood Ave., Holly Hill, FL 32117 Effective Date: __________________________ Hire Date: ______________________ Dept. Location: ________________________________________________
PLEASE PRINT CLEARLY
ENROLLMENT: CHANGE: * REASON FOR CHANGE: Please check appropriate box or enter code number from box on back ________
New Enrollment Add Change Terminate Marriage Change of Address Gain/Loss Other Coverage
Open Enrollment Birth Leave of Absence Medicare/Medicaid Entitlement
Waive Coverage Eff. Date:______/______/______ Adoption/Placement Workplace Change Judgment/Court Order
I. EMPLOYEE INFORMATION: (PLEASE PRINT) To be completed by all eligible employees, those waiving coverage, and former employees covered by COBRA.
Last Name: ______________________________________ First : _____________________ MI: _______ Prior Name (if applicable): ____________________________ Phone No.: (______) ____________________________ (home)
Street Address: _______________________________________________________________ City / State / Zip: ______________________________________________ Phone No.: (______) _____________________________ (work)
Mailing Address: ______________________________________________________________ City / State / Zip: ______________________________________________ Email Address: _______________________________________
Marital Status: Single Separated Plan Choice: LARGE GROUP SMALL GROUP Conversion
Married Widowed HMO POS Standard Basic Premium COBRA
Divorced Triple Option Triple Option Other _______________________
II. IMPORTANT INFORMATION: You must provide complete information for yourself and each dependent you are enrolling, adding or terminating.
Dependent children ages 0 - 19 may enroll, proof of Guardianship may be required. Dependent children 19-25 years of age who are dependent on you for support and a student may enroll. Any dependent child over 19 years of age who is
physically or mentally disabled may also be enrolled (please attach a doctor’s statement certifying that the dependent child cannot work for a living because of a disability which existed continuously from a date prior to 19 years of age.) All
dependent children must be listed as an exemption on your Federal Income Tax return. Proof of student status is required with this application and annually thereafter.
RELATION A D LAST NAME FIRST NAME MI SOC. SEC. NO. DATE OF BIRTH SEX PREVIOUS FHCP STUDENT OPTIONAL PRE-X
TO YOU D E MM/DD/YYYY MEMBER MEDICAL =S Enter appropriate code DATES
D L Yes - Y RECORD # number from box on back FHCP
No - N If Any Race
=D Use ONLY
Dependent Child F
Dependent Child F
Dependent Child F
III. CURRENT OR PRIOR HEALTH INSURANCE COVERAGE FOR THE LAST 12 MONTHS: (FOR ALL SMALL GROUP ENROLLEES OR LARGE GROUP LATE ENROLLEES)
FHCP must receive a copy or copies of a certificate of creditable coverage containing carrier and dates of previous coverage for each person to be enrolled; otherwise, pre-existing condition limitation may apply.
Health Insurance Company Name: ______________________________________ Customer Service Phone No.: ________________________________ Original Effective Date: _____________ Termination Date: _______________
IV. CERTIFICATION AND AUTHORIZATION: FHCP OFFICE USE ONLY:
I authorize the deduction from my earnings of any amount that may be required to pay the premium associated with the Florida Health Care Plan, Inc. (FHCP) health benefit plan that I have selected for myself and, if applicable,
my dependents. I agree to pay any subscription fees including copayments, coinsurance and deductibles associated with this coverage. I authorize any health care professional, health care facility, insurer, HMO, the Medical
Information Bureau, or any other entity having health or personal identification information as to me or my dependents to release it to FHCP, its contracted and staff providers, claims administration personnel, utilization/peer review
organizations, reinsurer, and insurance agents. In addition, information concerning health care advice, treatment, or supplies provided to me or my dependents related to coverage under the FHCP health benefit plan I have selected. Rider Code(s)
I understand that this information may be used for coordinating health care, health plan operations, evaluation and administration of claims, and business requirements imposed on FHCP by Federal or State law. I further understand
that this authorization may be withdrawn by me at any time as applicable according to my groups’ contract, but will otherwise continue to be valid during the entire term of my enrollment in FHCP. I understand that a facsimile of Group No.
this signed Authorization and Certification shall be as valid as the original. I certify that I read the statements on this form or that they have been read to me, and that all the information contained in Section II was provided by me
and is true and complete to the best of my knowledge. I understand that any material misrepresentation or material omission contained herein may be used to reduce or deny a claim or service or void the contract. I further understand Coverage Type
that no agent can modify this application, waive the answers to any questions, or suggest or complete the answers hereto. ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY
INSURER, FILES A STATEMENT OF CLAIM OR ANY APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE.
Signature: _____________________________________________________________________________________________________ Date: _______________________________
24-348/ EMPLOYEE ENROLLMENT FORM 1-02
FHCP - 117 - Rev. 8/05 WHITE - FHCP ENROLLMENT; YELLOW - EMPLOYER; PINK - EMPLOYEE
Please enter the appropriate Code #(s) for each member being enrolled
in the OPTIONAL box(es) on the reverse side of this form.
0 – Unknown
1 – White
2 – Black
3 – Other
4 – Asian
5 – Hispanic
6 – North American Native
7 – Hispanic or Latino
8 – Non Hispanic or Latino
Have you used any tobacco product in the last 30 days?
9 – Yes
10 – No
REASON FOR CHANGE CODES:
1– Employment Terminated B– Administrative
2– Dissatisfied with Services C– Divorce
3– Non-payment E– Reduction in Hours
4– Moving Out-of-Area H– No Longer Eligible
5– Not Affordable I– Age
6– Other Coverage
7– Seasonal Employment
8– Employer Cancels Coverage