individual plans enrollment application/change form … · individual plans enrollment application...

500 Patroon Creek Blvd.Albany, NY 12206-1057

(518) 641-3700 or 1-800-777-2273

Individual Plans Enrollment Application/Change Form

17-3747Form # 01-0018-2018 Continued on page 2 Page 1 of 3

PLEASE PRINT. For address and/or primary care physician changes call (518) 641-3700, 1-800-777-2273, or visit www.cdphp.com USE BLACK INK ONLY.Note: You cannot purchase an individual plan if you are enrolled in Medicare.

A. EXPLANATION (CHECK ALL THAT APPLY)

Reason for applying (Qualifying life event)New Enrollment: Change Enrollment:

Open Enrollment Termination Birth of a Child Member Requested Loss of Coverage Remove Dependents Only Marriage Deceased Court Order Other: (Reason and date of qualifying event) _______________________________ Other: (Reason and date of qualifying event) ___________________________________________________________________

B. COVERAGE INFORMATION (CHECK ALL THAT APPLY)

Requested Effective date: _________________________________ Is this for Child-Only coverage? No Yes (If yes, you must select a Standard plan.)

If Yes, indicate name of Responsible Adult: __________________________________

Do you have other children enrolled in a CDPHP Child-Only plan? If so, please list names: _______________________________________________________

Please select your plan and applicable riders.

HDHMO Qualified 44 Bronze* HDHMO Qualified 33 Silver* HMO Hybrid 23 Gold

HDHMO Qualified 40 Bronze Standard* Smart Deductible HMO Coinsurance 34 Silver HMO Copayment 20 Gold Standard

HMO Hybrid 13 Platinum HMO Copayment 30 Silver Standard

HMO Copayment 10 Platinum Standard

Optional riders: *HealthEquity Individual HSA Yes No

Dependent through Age 29 Coverage (The Custodial Agreement for this account will be sent to you under separate cover)

C. SUBSCRIBER INFO

For HMOs only, you and each dependent MUST select a Primary Care Physician (PCP). Females may also choose one OB/GYN. Also indicate if a member is a current patient and get the Physician # and Office Location from the provider directory or at www.cdphp.com.

1. Last Name First Name M.I. 4. Telephone: Primary Secondary

__________________________________________________ ____________________________ ______ ______________________________________________________________

2a. Street Address Apt. # 5. E-mail Address

__________________________________________________________________________________________ ____________________________________________________________

2b. City State ZIP 6. Social Security Number (Required)

__________________________________________________ ____ __________________________ ________________________________________________________

3a. Mailing Address Check here if same as street address Apt. # Date of Birth

__________________________________________________________________________________________ ________________________________________________________

3b. City State ZIP Sex: M F

__________________________________________________ ____ __________________________ Medical Add or Delete

Have you obtained stand-alone dental coverage that provides a pediatric dental essential health benefit through a New York Health Benefit Exchange-certified stand-alone dental plan offered outside the New York Health Benefit Exchange? Yes No

If you answered yes, please provide the name of the company issuing the stand-alone dental coverage. _______________________________

If you answered no, we will provide you coverage of the pediatric dental essential health benefit. Additional cost may apply. See rate sheet for your county.

Primary Language (optional*): Spoken: _________________________________________ Written: ________________________________________

Ethnicity (optional*): White Black American Indian/Alaska Native Asian/Pacific Islander Hispanic/Latino Other

Previous coverage: Yes Previous carrier: ___________________________________ Effective from: ______________ To: ________________

HMO onlyPhysician (PCP) Last First Phys # Current Patient?

__________________________________________________________ _________________________________ ____________________________________

OB/GYN Last First Phys # Current Patient?

__________________________________________________________ _________________________________ ____________________________________

*You are not required to answer. This information is important, however, as it helps us understand the diversity of our membership.

D. DEPENDENT INFO

For HMOs only, you and each dependent MUST select a Primary Care Physician (PCP). Females may also choose one OB/GYN. Also indicate if a member is a current patient and get the Physician # and Office Location from the provider directory or at www.cdphp.com.

8a. Last First M.I. SSN (Required) Date of Birth Medical

____________________________________________ _____________________________ ______ ________________________ _______________________ Add or Delete

Rel: Spouse Other Sex: M F Disabled








__________________________________________________________ _________________________________ ____________________________________


__________________________________________________________ _________________________________ ____________________________________

8b. Last First M.I. SSN (Required) Date of Birth Medical

_____________________________________________ _____________________________ ______ ________________________ ________________________ Add or Delete

Rel: Son Daughter Disabled








__________________________________________________________ _________________________________ ____________________________________


__________________________________________________________ _________________________________ ____________________________________

8c. Last First M.I. SSN (Required) Date of Birth Medical

_____________________________________________ _____________________________ ______ ________________________ ________________________ Add or Delete









__________________________________________________________ _________________________________ ____________________________________


__________________________________________________________ _________________________________ ____________________________________

*You are not required to answer. This information is important, however, as it helps us understand the diversity of our membership.17-3747

Form # 01-0018-2018 Continued on page 3 Page 2 of 3

D. DEPENDENT INFO Contd

8d. Last First M.I. SSN (Required) Date of Birth Medical_____________________________________________ _____________________________ ______ ________________________ ________________________ Add or Delete









__________________________________________________________ _________________________________ ____________________________________


__________________________________________________________ _________________________________ ____________________________________

*You are not required to answer. This information is important, however, as it helps us understand the diversity of our membership.

E. OTHER INSURANCE

Do you, your spouse, or any of your dependents have any other medical insurance that will be maintained in addition to CDPHP? Yes: If yes, complete below. No

9. Policyholder name Policy # Insurance carrier Employer name

___________________________________________________ _________________________ ___________________________ _____________________________________

Date of birth: _________________________________ Address: __________________________________________________________________________________

Effective date: __________________________________ Coverage type: Hospital Medical Drug Dental Vision

Covered IndividualsCheck all that apply Self Spouse Dependents

Note: Make sure you sign and date the application below.

F. SIGNATURE: AGREEMENT: I hereby represent that all information furnished by me hereon is true and complete to the best of my knowledge and that I have read the important information on the last page of this form.

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed $5,000 and the stated value of the claim for each such violation.

10. Applicants Signature: ______________________________________________________________________ 11. Date: __________________________________

(For Child-Only Plans: Responsible Adult Signature.)

IMPORTANT INFORMATION

Failure to complete any sections will result in a processing delay of your application, member ID cards and, claims payment.

If you should have any questions about this Enrollment Application/Change Form, please call the CDPHP member services department at (518) 641-3700 or 1-800-777-2273. Thank you for choosing CDPHP for your health care coverage.

Your signature on this application hereby affirms the following:

On behalf of myself and any dependents listed, I hereby apply for coverage under the Individual Contract issued by Capital District Physicians Health Plan, Inc. and/or CDPHP Universal Benefits, Inc. (CDPHP UBI), and/or Delta Dental of New York, Inc.

I understand that the benefits for which I (we) will be eligible are in accordance with those described in the Individual Contract and any attached riders. I further understand that for HMO benefits provided by Capital District Physicians Health Plan, Inc., except for emergencies, covered services must be obtained through a participating physician (unless otherwise noted in rider) or in a participating hospital (unless otherwise noted in rider) when admitted or referred by a participating physician (unless otherwise noted in rider), and also that certain services may require a copayment (unless otherwise noted in rider) by me (or my dependents) directly to the provider of such services.

I understand that unresolved grievances are subject to the procedure specified in the Individual Contract.

CDPHP COMPANIESCapital District Physicians Health Plan, Inc.

CDPHP Universal Benefits, Inc.Capital District Physicians Healthcare Network, Inc.

Delta Dental Service Plans are underwritten and administered by Delta Dental of New York, Inc.

Delta Dental of New YorkOne Delta DriveMechanicsburg, PA 170551-800-932-0783TTY/TDD 1-888-373-3582www.deltadentalins.com

A REGISTERED MARK OF DELTA DENTAL PLANS ASSOCIATION

17-3747Form # 01-0018-2018 Page 3 of 3

Discrimination is Against the LawCapital District Physicians Health Plan, Inc. (CDPHP) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. CDPHP does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

CDPHP:

fProvides free aids and services to people with disabilities to communicate effectively with us, such as:

Qualified sign language interpreters

Written information in other formats (large print, audio, accessible electronic formats, other formats)

fProvides free language services to people whose primary language is not English, such as:

Qualified interpreters

Information written in other languages

If you need these services, contact the CDPHP Civil Rights Coordinator.

If you believe that CDPHP has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: CDPHP Civil Rights Coordinator, 500 Patroon Creek Blvd., Albany, NY 12206, 1-844-391-4803 (TTY/TDD: 711), Fax (518) 641-3401. You can file a grievance by mail, fax, or electronically at https://www.cdphp.com/customer-support/email-cdphp. If you need help filing a grievance, the CDPHP Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019 (TDD 1-800-537-7697).

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

16-1786 | 1016

Multi-language Interpreter Services

ATTENTION: If you speak a non-English language, language assistance services, free of charge, are available to you. Call the number on your member ID card (TTY: 711).

ATENCIN: Si habla otro idioma que no es el ingls, tiene a su disposicin servicios gratuitos de asistencia lingstica. Llame al nmero que figura en su tarjeta de identificacin de miembro (TTY: 711).

ID 711

: , . ID (: 711).

ATANSYON: Si ou pale yon lang ki pa Angle, wap jwenn svis asistans lang gratis disponib pou ou. Rele nimewo ki sou kat ID manm ou a (TTY: 711).

:. ID(TTY: 711).

ATTENZIONE: Se non parla inglese n una lingua anglofona, sono disponibili servizi gratuiti di assistenza linguistica. Chiami il numero presente sulla scheda ID dei membri (TTY: 711).

, : ) TTY:711(ID.

, (TTY: 711)

UWAGA: Jeeli mwisz po polsku, moesz skorzysta z bezpatnej pomocy jzykowej. Zadzwo pod numer na Twojej czonkowskiej karcie ID (TTY: 711).

. : ). TTY :711 (

ATTENTION : Si vous parlez franais, des services d'aide linguistique vous sont proposs gratuitement. Appelez au numro indiqu sur votre carte de membre(ATS : 711).

: )TTY: 711(

ATENSYON: Kung nagsasalita kayo ng wikang iba sa Ingles, magagamit niyo ang mga serbisyo sa tulong sa wika nang walang bayad. Tawagan ang numero sa inyong card miyembro ID (TTY: 711).

: , . (TTY: 711).

VINI RE: Nse flisni nj gjuh jo-anglisht, shrbime falas t ndihms s gjuhs jan n dispozicion pr ju. Telefonojini numrit n kartn tuaj t ID t antarit(TTY: 711).

16-1780

undefined_2: New Enrollment: Change Enrollment: Deceased: B COVERAGE INFORMATION CHECK ALL THAT APPLY: Is this for ChildOnly coverage: Yes If yes you must select a Standard plan: If Yes indicate name of Responsible Adult: Please select your plan and applicable riders: Optional riders: 1 Last Name: First Name: MI: 4 Telephone Primary: 2a Street Address: 5 Email Address: 2b City: State: ZIP: 6 Social Security Number Required: Check here if same as street address: 3a Mailing Address: Date of Birth: 3b City: State_2: ZIP_2: Sex: Medical: If you answered yes please provide the name of the company issuing the standalone dental coverage: standalone dental plan offered outside the New York Health Benefit Exchange: If you answered no we will provide you coverage of the pediatric dental essential health benefit Additional cost may apply See rate sheet for your county: Written: Primary Language optional: Yes_2: American IndianAlaska Native: AsianPacific Islander: HispanicLatino: HMO onlyPhysician PCP Last: First: Phys: C HMO Current Patient: OBGYN Last: First_2: Phys_2: C OB GYN Current Patient: 8a Last: First_3: MI_2: SSN Required: Date of Birth_2: Rel: D 8a Medical Add or Delete: Have you obtained standalone dental coverage that provides a pediatric dental essential health benefit through a New York Health Benefit Exchangecertified: If you answered yes please provide the name of the company issuing the standalone dental coverage_2: If you answered no we will provide you coverage of the pediatric dental essential health benefit Additional cost may apply See rate sheet for your county_2: Written_2: Yes_4: Previous carrier: American IndianAlaska Native_2: AsianPacific Islander_2: HispanicLatino_2: HMO onlyPhysician PCP Last_2: First_4: Phys_3: 8a HMO Current Patient: First_5: Phys_4: OBGYN Last 1: 8a OB GYN Current Patient: 8b Last: First_6: MI_3: SSN Required_2: Date of Birth_3: Rel_2: D 8b Medical Add or Delete: Have you obtained standalone dental coverage that provides a pediatric dental essential health benefit through a New York Health Benefit Exchangecertified_2: If you answered yes please provide the name of the company issuing the standalone dental coverage_3: If you answered no we will provide you coverage of the pediatric dental essential health benefit Additional cost may apply See rate sheet for your county_3: Written_3: Yes_6: Previous carrier_2: American IndianAlaska Native_3: AsianPacific Islander_3: HispanicLatino_3: HMO onlyPhysician PCP Last_3: First_7: Phys_5: 8b HMO Current Patient: OBGYN Last_2: First_8: Phys_6: 8b OB GYN Current Patient: 8c Last: First_9: MI_4: SSN Required_3: Date of Birth_4: Rel_3: D 8c Medical Add or Delete: Have you obtained standalone dental coverage that provides a pediatric dental essential health benefit through a New York Health Benefit Exchangecertified_3: If you answered yes please provide the name of the company issuing the standalone dental coverage_4: If you answered no we will provide you coverage of the pediatric dental essential health benefit Additional cost may apply See rate sheet for your county_4: Written_4: Yes_8: Previous carrier_3: American IndianAlaska Native_4: AsianPacific Islander_4: HispanicLatino_4: HMO onlyPhysician PCP Last_4: First_10: Phys_7: 8c HMO Current Patient: OBGYN Last_3: First_11: Phys_8: 8c OB GYN Current Patient: 8d Last: First_12: MI_5: SSN Required_4: Date of Birth_5: Rel_4: D 8d Medical Add or Delete: Have you obtained standalone dental coverage that provides a pediatric dental essential health benefit through a New York Health Benefit Exchangecertified_4: If you answered yes please provide the name of the company issuing the standalone dental coverage_5: If you answered no we will provide you coverage of the pediatric dental essential health benefit Additional cost may apply See rate sheet for your county_5: Written_5: Ethnicity optional: Yes_10: American IndianAlaska Native_5: AsianPacific Islander_5: HispanicLatino_5: HMO onlyPhysician PCP Last_5: First_13: Phys_9: 8d HMO Current Patient: OBGYN Last_4: First_14: Phys_10: 8d OB GYN Current Patient: Do you your spouse or any of your dependents have any other medical insurance that will be maintained in addition to CDPHP: 9 Policyholder name: Policy: Insurance carrier: Employer name: Date of birth: Address: Effective date: Coverage type: 11 Date: Sexp2: DisabP2: Disabled_2: Disabled_3: Disabled_4: Covered Individuals Self: Covered Individuals Spouse: Covered Individuals Dependents: HealthEquity Individual HSA:

individual plans enrollment application/change form … · individual plans enrollment application...

Documents