2018 Community Psychiatry Medical Enrollment Form

Medical / Dental / Life / Vision Enrollment Application

721 South Parker, Suite 200, Orange, CA 92868 (800) 558-8003 www.calchoice.com •

COMPLETE WAIVER SECTION ON PAGE 4 IF YOU OR ANY OF YOUR DEPENDENTS ARE NOT ENROLLING. COMPLETE AN EMPLOYEE CHANGE REQUEST FORM IF YOU ARE AN EXISTING MEMBER AND NEED TO MAKE CHANGES. FOR PRIMARY CARE PHYSICIAN CHANGE ONLY, PLEASE CONTACT YOUR HEALTH PLAN DIRECTLY.

Select one

New Business

New Hire

New Renewal

New COBRA Qualifying/Triggering Event

A

Personal Information

Group #

Company Name

(exclude any orientation periods, if applicable) Full-Time Employment Date (MM/DD/YYYY) / /

Employee Job Title

Married

Single

Domestic Partner

Gender

M F

Status

Employee Social Security #

Employee Last Name

M.I.

Date of Birth (MM/DD/YYYY) / /

Employee First Name

Physical Address (Do not use P.O. Box) Home Phone # (XXX) XXX-XXXX - -

E-mail Address

City

Apt. #

State

ZIP Code

County

City

Apt. #

Mailing Address (if different from above)

State

ZIP Code

County

B

Enrollment Information

Complete this section ONLY if you are electing medical, dental and/or vision for yourself and dependents.

Employee

Child 1

Child 2

Child 3

Spouse/Domestic Partner

Life only Medical Dental Vision

Medical Vision Dental

Medical Dental Vision

Medical Dental Vision

Medical Dental Vision

Enrolling For?

Last Name First Name

Domestic Partner

Spouse

Relationship to Employee

Social Security # required!

Social Security # required!

Social Security # required!

Social Security # required!

Social Security #

Male

Female

Male

Female

Male

Female

Male

Female

Gender

MM/DD/YYYY

MM/DD/YYYY

MM/DD/YYYY

MM/DD/YYYY

Date of Birth

Disabled?

Yes

No

Yes

No

Yes

No

(Complete only if over age 26)  To enroll more dependents, complete sections A & B on an additional application. COBRA Applicants

/ / Date of Qualifying/Triggering Event (MM/DD/YYYY)

Please check COBRA type

Indicate Qualifying/Triggering Event Termination of employment

Child no longer eligible Medicare entitlement Divorce/legal separation Death of employee

COBRA Cal-COBRA

Reduction of hours

PLEASE SIGN AND DATE APPLICABLE SECTIONS INSIDE APPLICATION

40859

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CC 0310 9/2017 Eff. 1/1/2018

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