Application for Enrollment
USA Health & Dental Plan
PLEASE PRINT CLEARLY AND BE SURE TO SIGN AND DATE THIS FORM
EMPLOYEE INFORMATION - PLEASE PRINT CLEARLY
EMPLOYEE NAME (LAST):
(FIRST):
STREET ADDRESS:
CHECK ONE:
MALE
FEMALE
(INITIAL):
CITY:
CHECK ONE:
SINGLE
MARRIED
DIVORCED
WIDOWED
STATE:
CHECK ONE:
Dr.
Mr.
TYPE OF COVERAGE SELECTED:
ZIP:
EMPLOYEE DATE OF BIRTH:
GROUP NUMBER:
PHONE NUMBER:
EMPLOYEE SOCIAL SECURITY NUMBER:
Mrs.
Ms./Miss
EMPLOYEE (J) NUMBER:
J
INDIVIDUAL
FAMILY
NATURE OF APPLICATION – CHECK THE APPROPRIATE BOX FOR THE ACTION DESIRED:
NEW CONTRACT APPLICATION
CHANGE CONTRACT
CANCEL CONTRACT
ADD/REMOVE DEPENDENT
NAME CHANGE
ADD SPOUSE
ADDRESS CHANGE
ADD DEPENDENT CHILD
TYPE OF COVERAGE CHANGE
REMOVE SPOUSE
CHANGE COB INFORMATION
REMOVE DEPENDENT CHILD
DATE EVENT OCCURRED (Example: Date of marriage, birth date of child, date of death, etc.):
LIST ALL DEPENDENTS ELIGIBLE UNDER THIS CONTRACT AND PROVIDE SOCIAL SECURITY NUMBER AND/OR MEDICARE NUMBER (HICN)
The Social Security Number for the employee and ALL dependents must be provided in order for this application to be processed.
SOCIAL SECURITY NUMBER
DATE OF BIRTH
LAST NAME
FIRST NAME
INITIAL
RELATIONSHIP
AND/OR HIC NUMBER
MONTH
DAY
YEAR
SPOUSE
Male
Female
SON
DAUGHTER
SON
DAUGHTER
SON
DAUGHTER
SON
DAUGHTER
COORDINATION OF BENEFITS – MANDATORY INFORMATION
If you, your spouse, or dependents are covered by any other group health insurance, you are required to provide the following information:
NAME OF CONTRACT HOLDER:
POLICY, ID, CONTRACT OR CERTIFICATE
TYPE OF COVERAGE:
NAME OF INSURANCE COMPANY
NUMBER:
INDIVIDUAL
FAMILY
EMPLOYER’S NAME:
EMPLOYER’S STREET ADDRESS, CITY, STATE, & ZIP:
GROUP NUMBER:
COVERAGE EFFECTIVE DATE:
NAME OF MEMBER ENTITLED TO MEDICARE BENEFITS:
MEDICARE NUMBER (HICN):
PART A
PART B
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EMPLOYEE CERTIFICATION – CHECK ONE
I waive my rights to health and dental benefits and do not wish to enroll.
I am requesting cancellation of my existing benefits as indicated.
I am applying for coverage under the USA Health & Dental Plan (Plan).
I understand that my application is subject to the terms and conditions of the Plan and that coverage is subject to the eligibility
rules and plan of benefits as stated in the USA Health and Dental Plan Member Handbook.
I understand that any misrepresentation is fraud and will be pursued to the fullest extent allowed by law.
I understand that coverage under the Plan will not become effective until my application is accepted by evidence of issuing an
identification card or other written notice.
I agree to notify the USA Human Resources Department if an eligible dependent has a change-in-status, especially if a dependent is
no longer a dependent due to divorce.
I authorize my doctor, hospital or anyone else to give all medical records for anyone covered under my coverage to the claims
administrator for the operation of the Plan including determination of eligibility and benefits.
I agree to cooperate with the claims administrator and provide information required to administer the Plan, pay claims, coordinate
benefits with other coverage, subrogate against another responsible party or recover benefits paid in error. I agree that benefits
may be paid directly to providers of service and such payment will release the Plan of its benefit obligation.
TOBACCO USE CERTIFICATION
The USA Health & Dental Plan is committed to helping you achieve your best health. The Wellness Incentive is
available to all employees. If you think you might be unable to meet the standard under this Wellness Program, you
may qualify for an opportunity to earn the same reward by different means. Contact the USA Human Resources
Department for additional information.
HAVE YOU OR YOUR SPOUSE USED TOBACCO PRODUCTS WITHIN THE LAST SIX (6) MONTHS? :
Yes
No
Further, I attest that everything in the application is true.
Signature of Employee
Date Signed
Beginning in 2014, the Affordable Care Act (ACA) prohibits pre-existing condition waiting periods. In compliance with
the Affordable Care Act (ACA), effective January 1, 2014, the USA Health & Dental Plan no longer utilizes a pre-existing
condition waiting period.
Departing employees or dependents no longer eligible will be provided a Certificate of Creditable Coverage from this
Plan that can be submitted to possibly offset the waiting period for coverage of pre-existing conditions under a new
health plan which may not be subject to the ACA mandates. Departing employees and dependents no longer eligible
for coverage will be entitled to COBRA coverage, and may be eligible to purchase coverage through the Health
Insurance Marketplace.
STOP – TO BE COMPLETED BY A UNIVERSITY OF SOUTH ALABAMA HUMAN RESOURCES DEPARTMENT REPRESENTATIVE
All the information appears to be complete and correct.
Signature of HR Representative
Date Signed
University of South Alabama
Human Resources Department
650 Clinic Drive
Technology & Research Park, Building 3 – Suite 2200
Mobile, AL 36688
Phone: (251) 460-6133
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