MVP Medical Plan
Change Form
Social Security Number
Last Name
Mailing Address
First Name
Middle Initial
Cell Phone
City
State
Zip
County
Male
Female
Are you
Married?
Home Phone
Sex
Yes
No
If Yes, Date of Marriage
ACCEPT/DECLINE
I am accepting ACA compliant med insurance
I am declining ACA compliant med insurance
Employer Name: Geotemps, Inc.
Assigned Branch:
Are you Actively at Work?
Yes
Average Hours Worked Per Week
REASON FOR APPLICATION OF THE Preferred Provider (PPO)
New Enrollment, List E ffective Date
Coverage Termination
Open Enrollment
Change Address/Name
Add Dependent as Result of Life Event
Delete Dependent (list names below)
(1)
Marriage,
(date)
(2)
Birth of Child,
(date)
(3)
Adoption of Child,
(date)
(4)
Loss of Coverage,
(date)
No
Are you covering any dependents?
Yes
RELATION TO EMPLOYEE LAST NAME
Spouse
(A) Dependent Child
(B) Dependent Child
(C) Dependent Child
(D) Dependent Child
No
FIRST NAME
Do you or your dependents have other medical coverage?
Yes
SOCIAL SECURITY NUMBER
No
Name of Insured
Social Security Number
Name of Insurance Company
Employer of Insured
Employer Address
City
Name of Insured
Social Security Number
Name of Insurance Company
Employer of Insured
Employer Address
City
If yes, who?
DATE OF BIRTH
Self
SEX OF DEPENDENT
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Spouse
Child(ren)
Group Number
State
Zip
Group Number
State
Zip
To the best of my knowledge, I believe the above information is true and correct. I understand that false or inaccurate information may result
in the termination of coverage or the non-payment of benefits.
Employee Name (Printed)
Employee Signature
Date Signed
WAIVER / REJECTION OF HEALTH COVERAGE: After careful consideration, I do not wish to participate in any of the available plans. I also
realize I will NOT be able to re-enroll until next open enrollment period and then I may be required to provide Medical Proof of Insurability.
Employee Name (Printed)
Employee Signature
Date Signed
EMPLOYEE MEDICAL HISTORY QUESTIONNAIRE
Please provide the following information for yourself as well as for any family members on whose behalf you are electing medical coverage.
Relation to Employee
Last Name
First Name
Date of Birth
Sex of Dependent
Male
Female
Spouse
Male
Female
(A) Dependent Child
Male
Female
(B) Dependent Child
Male
Female
(C) Dependent Child
Male
Female
(D) Dependent Child
Yes
No
On behalf of yourself and each of your family members listed above, please respond to each of the questions listed below.
When you have finished answering all questions, please sign and date the bottom of this form.
1. Are you or any of your family members listed above currently confined or have you been confined to a hospital/other institution in the
twelve months prior to the signing of this form? If "Yes", please provide the details requested below.
2. Have you or any of your family members listed above had surgery or other procedure(s) on an outpatient basis in the twelve months
prior to the signing of this form? If "Yes", please provide the details requested below
3. Are you or any of your family members listed above scheduled for or planning on having any inpatient or outpatient surgeries or other
procedures in the next twelve months following the signing of this form? If "Yes", please provide the details requested below
4. Are you or any of your family members listed above currently unable to work, attend school, perform daily tasks, etc. due to illness
/injury? If "Yes", please provide the details requested below
5. Are you or any of your family members listed above on COBRA? Have you or any of your family members recently received or are
you/they expecting to receive a COBRA notification letter? If "Yes", please provide the details requested below.
6. Have you or any of your family members listed above been diagnosed with and/or received treatment for any of the diagnoses listed
on the attached list? If "Yes", please provide the details requested below
If you answered" Yes" to any of the above questions, please provide the details below. Should you need more space, please attach an
additional page to this form and continue your remarks with the corresponding question number. Wherever possible, provide the dollar
amounts initially charged by the medical providers before your insurance company paid benefits
Question
Name of person to
Treatment or
Diagnosis or
Details including, but not limited to Medical/Rx services received
# (1-6)
be covered
Event Date
Medical Condition
and/or planned, treatment plan, prognosis and approximate costs
AUTOIMMUNE DISORDERS
AIDS, cytomegalovirus, Karposi’s sarcoma,
pneumocystis carinii, pneumonia
ENDOCRINE DISORDERS
diabetes
PREGNANCY
congenital (birth)defects/disorders, high risk
pregnancy, hydrocephalus, multiple births, prematurity,
spina bifida
BLOOD DISORDERS
clotting disorders, cystic fibrosis, hemophilia, sicklecell anemia
INFECTIOUS and PARASITIC DISEASES
necrotizing fasciitis, sepsis
RESPIRATORY SYSTEM
chronic obstructive, pulmonary disease, emphysema,
primary pulmonary, hypertension, respiratory
distress/failure, tuberculosis
CANCER
any type
MUSCULOSKELETAL DISORDERS
intervertebral disc disorders, kyphosis, scoliosis
SYSTEMIC DISORDERS
lupus, neoplasms – any type/site, rheumatoid arthritis,
scleroderma
CIRCULATORY SYSTEM
aneurysm – any site, cardiomyopathy, cardiovascular
disease, cerebrovascular accident (stroke), congestive
heart failure, coronary artery disease, hemorrhage –
any kind, malignant hypertension, myocardial
infarction, peripheral vascular disease
INJURIES
amputation(s), multiple fractures, head injuries (e.g.
coma, traumatic brain injury), second/third‑degree
burn, spinal cord injuries
TRANSPLANTS
any type
DIGESTIVE SYSTEM
cirrhosis, Crohn’s disease, hepatitis, liver failure,
pancreatitis, ulcerative colitis
NEUROLOGIC DISORDERS
Alzheimer’s disease, cerebral palsy, Guillain-Barre
syndrome, multiple sclerosis, muscular dystrophy,
myasthenia gravis, paralysis ‑ any type, Parkinson’s
disease
URINARY SYSTEM
glomerulonephritis, renal failure (with or without
dialysis)
EATING DISORDERS
anorexia nervosa, bulemia, morbid obesity