Please print neatly using
black or blue ballpoint pen
Addition/Termination Change Form
P. O. Box 29142, Hot Springs, AR 71903 • 1-800-444-6222
Many transactions can be completed online at the employer area of our website www.oxfordhealth.com
A. Employer/Employee Information (To be completed by the employer)
Group ID Number:
Employee Insurance ID Number:
X
Effective Date
Termination
Change
Address changes can be done
online or by calling Oxford.
Group Name:
Employer Signature
Date
Employee Name:
B. Transaction
ALL DATES MUST BE: MM/DD/YYYY
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OBRA or
C
State Continuation
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/
Required Information
Who:
Employee
Reason: Left Employer
Discontinue
NY Young Adult
Spouse/Partner
Discontinue COBRA
Dependent(s)
Switched Plans
Other:
NY Young Adult
Who:
Effective Date:
/
/ SS#:
Last Name:
Date of Birth:
/
/ Middle Intial:
First Name:Other:Gender: M
F
Who:
Employee
Reason:
Left Employer
Date of Event:
Spouse/Partner*
Hours Reduction
/
/
Dependent(s)*
Other:
*A New Member Enrollment Form is required for: Loss of Dependent Status, Divorce/Separation, or Death of Subscriber.
Transfer
Complete entire section
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Addition
Complete WHO, REASON
and section c below
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New Plan CSP:
New Billing Group:
Reason:
Spouse
Reason: Who:
Civil Union
Domestic Partner
Dependent(s)
Spouse
C. Additional Information
Retiree Drug Subsidy: Actively Working: Enrolled in Medicare Part:
Open Enrollment
Loss of Coverage
Birth/Adoption
Other:
Dependent
Yes
No
Yes
No
A
B ­ D
Date of Marriage
Date of Civil Union
Date of Partnership
Dependent
Social Security Number:
Last Name:
First Name, Middle Initial:
Date of Birth: (mm/dd/yYYy)
/
Gender and Disability Status:
M
Primary Care Physician (PCP) ID Number:
PCP Name: ( If an existing patient, check “Yes”. )
What coverage you had prior to this.
Policy Number:
Carrier:
From Date:
Through Date:
Medicare
Check appropriate
box and list
effective date:
Pharmacy Policy Number:
Carrier:
Policy Holder:
Group Number:
Same for all
Effective Date:
/
/
Medical
Same for all
Disabled
Policy Number:
Carrier:
Policy Holder:
Effective Date:
M
/
F
/
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Disabled
_________________________________ _________________________________
Yes
M
F
/
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Disabled
_________________________________
Yes
ull-time Student
F
(Age 19 - 23)
Yes
ull-time Student
F
(Age 19 - 23)
_________________________________ __________________________________
__________________________________
_________________________________ __________________________________
__________________________________
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Spouse
D. Coordination of Benefits
/
Actively employed
Not actively employed
Check all that apply:
Prior Carrier F
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Part A
Part B
Part D
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Dependent
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Part A
Part B
Part D
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Dependent
/
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Part A
Part B
Part D
/
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__________________________________ ___________________________________
___________________________________
__________________________________ ___________________________________
___________________________________
___________________
___________________
___________________
BIN:
BIN:
BIN:
PCN:
PCN:
__________________________________ ___________________________________
__________________________________ ___________________________________
__________________________________ ___________________________________
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PCN:
___________________________________
___________________________________
___________________________________
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ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON AN APPLICATION FOR INSURANCE IS SUBJECT TO CRIMINAL AND CIVIL penalties
Employee Signature
Date
X //
MS-07-422 Rev 1 02-2013
White Copy: insurerYellow Copy: Employee
003 Rev 9
UHCEW630241-000