All Savers
Employee Enrollment Alternate Funding
Please send correspondence to P.O. Box 19032, Green Bay, WI 54307-9032 1-800-232-5432
(Please fill out the entire enrollment form to avoid processing delay. Please clearly print all information.)
Enrollee Social
Security Number
Group No.
Enrollee Information
Employer Name
Employer Address (If more than one location)
Last
Name
First
Name
Single
Married
Address
Phone #
Initial
City
State ZIP
Gender
Date of Birth
/
/
County
Height
Weight
Email Address
Date Employed Full Time
/
/
Average Hours
Worked Per Week
Occupation
Are you an independent contractor?
Yes
No
Enrollee and Dependent Information (Only for those applying).
If you need to list additional dependents, please use lined paper, sign and date it, and check this box:
Enrollee
Spouse
Child 1
Child 2
Child 3
Child 4
First Name
Middle Initial
Last Name
Gender
Date of Birth
F
/
M
/
F
/
M
/
F
/
M
/
F
/
M
/
F
/
Height
Weight
Social Security Number
Primary Care Physicians Name
Eligibility and Other Insurance (insurance that will be kept in addition to this coverage)
Currently Working Full Time
Yes
Yes
Yes
Yes
Yes
Yes
Plan to Keep Other Insurance Coverage
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Other Insurance Policy Number
Name of Other Insurance Company(ies)
Covered by Medicare/Medicaid
Medicare/Medicaid Coverage
Effective Date
Coverage and Change Request Information
Medical:
Employee
Family
Employee/Spouse
Employee/Dependent Child(ren)
Name of Medical Plan You Have Selected:__________________________________________________________________________________
Marriage
Divorce
Adoption
Returning to School Full Time
Court Order Date of Event: __________________
Change Request:
(you may be required to provide proof of event)
Attach a written and signed statement by the employer for a requested coverage effective date other than employee effective date.
Effective date may not be guaranteed.
Page 1 of 4
EE-AP-202-0713
Medical History
Has anyone on this enrollment form been diagnosed, consulted with, or been examined or treated by any health care professional
during the last 10 years for any illness, injury, or health condition in any of the categories listed below? If yes, please check the box
that most appropriately describes the problem and explain fully below. All statements contained in this entire form must be
true and correct and no material information can be withheld or omitted.
1 Cancer/Tumor
Yes
No
Breast
Cervical
2 Heart/Circulatory
Yes
No
Aneurysm
Bypass
Angioplasty/Stent
Congestive Heart Failure
Heart Disease
Elevated Cholesterol/Triglycerides
High Blood Pressure
Stroke
Angina
Hemophilia
Blood Clots
Pacemaker/ICD
Blood Disorder
Sickle Cell Anemia
Other________________________________________
3 Reproductive
Yes
No
Current Pregnancy (due date__________ if multiples #_______)
Pregnancy Complications
Fibroids
Menstrual Disorders
Breast Disorders
Endometriosis
Infertility
Other________________________________________
4 Intestinal/
Endocrine
Yes
No
Chronic Pancreatitis
Colon Disorder
Crohns
Ulcerative Colitis
Diabetes
Cirrhosis
Hepatitis B/C
Reflux
Liver Disorder
Ulcer
Growth Hormones
Gallbladder
Gastric Bypass
Other________________________________________
5 Brain/Nervous
Yes
No
Alzheimers
Cerebral Palsy
Migraines
Parkinsons Disease
Head Injury
Cyst
6 Immune
Yes
No
Scleroderma
ALS
Psoriasis
AIDS
HIV+
Other________________________________________
7 Lung/Respiratory
Yes
No
Allergies
Asthma
Cystic Fibrosis
Emphysema
Sarcoidosis
Lung Disorders
Tuberculosis
Sleep Apnea
Chronic Bronchitis
Pneumonia
Other________________________________________
8 Eyes/Ears/
Nose/Throat
Yes
No
Acoustic Neuroma
Cataracts
Cleft Lip/Palate
Deviated Septum
Glaucoma
Retinopathy
Chronic Ear Infections
Chronic Sinusitis
Other________________________________________
9 Urinary/Kidney
Yes
No
Kidney Stones
Renal Failure
10 Bones/Muscles
Yes
No
Rheumatoid Arthritis
Osteoarthritis
Bulging/Herniated Disc
Joint injury
Fibromyalgia/Chronic Fatigue Syndrome
Chronic Pain Syndrome
Shoulder Disorder
Spina Bifida
Back Disorder
Neck Disorder
Other____________
11 Behavioral Health
Yes
No
Anxiety/Depression
ADHD
Bipolar Depression
Manic Depression
Schizophrenia
Autism
Eating Disorder
Suicide Attempt
Inpatient Alcohol/Drug
Inpatient Mental Health Hospital
Substance Abuse
Other_________________________
12 Transplant
Yes
No
Bone Marrow
Organ
Discussed Possible Future Transplant
Other________________________________________
13 Other
Yes
Condition not mentioned above with claims in excess of $5,000
No
Colon
Leukemia
Lymphoma
Liver
Lung
Melanoma
Testicular
Brain
Ovarian
Prostate
Other Cancer_
Non-Malignant Tumor Location of Tumor____________________________
Multiple Sclerosis
Paralysis
Seizures/Epilepsy
Other________________________________________
Lupus
Immuno Deficiency
Kidney Disorders
Bladder Disorders
Polycystic Kidney Disease
Other________________________________________
Stem Cell
Disability
Prostate Disorder
Knee Disorder
Transplant Complications
Congenital Disorder
14 Tobacco
Yes
No
Anyone on this enrollment form used tobacco products in the past 12 months: Person______________________
15 Medications
Yes
No
Current Medications:
Person____________________ # of Meds____ Person___________________ # of Meds____ ( list meds below)
Medications taken within the past 12 months:
Person____________________ # of Meds____ Person___________________ # of Meds____ (list meds below)
16 Number of times anyone on this enrollment form has consulted with or been examined by any health care professional in the last 12 months:
Person____________________ Times_____ Person_____________________ Times_____ Person____________________ Times_____
Please give details of all yes answers above. (If additional space is required, please attach a separate sheet and date and sign that sheet).
Question #
Person
Condition/Diagnosis
Treatment /Meds
Page 2 of 4
EE-AP-202-0713
Physicians Name
Dates Treated
Prognosis
Prior Medical Coverage Information
Yes
No Have you or any dependents applying for coverage been covered by this employers prior group medical plan?
Yes
No H
ave you or any dependents applying for coverage been covered by any medical plan other than this employers prior group plan?
If yes:
Insurance Company Name_____________________________________ Phone # _______________________ Policy/Group #______________
Termination Date ______________________ Effective Date______________________ Reason for Termination___________________________
Who was covered?______________________________________________________________________________________________________
Type of Plan:
Prior Employer Group Plan
Spouses Employer Group Plan
Individual Policy
Other_____________________________
Waiver (Please complete if you are waiving medical coverage.)
I waive medical coverage for:
Self (and dependents)
Spouse
Dependent Children
Please state reason for waiving coverage:__________________
Qualifying Coverage:_________ Other____________________
If I have waived coverage for myself and/or my dependents (including my spouse) because of other health insurance coverage, I
may in the future be able to enroll myself and/or my dependents in the plan, provided that I request enrollment within 31 days after
my other coverage ends because of involuntary loss of other coverage (divorce, death, legal separation, termination of employment,
reduction in number of hours of employment). In addition, if I have a new dependent as a result of marriage, birth, adoption, or
placement for adoption, I may be able to enroll my dependents, provided that I request enrollment within 31 days after the date of
the event.
Applicant Signature X __________________________________________________________ Date ____________________
YOUR RIGHTS REGARDING THE RELEASE AND USE OF GENETIC INFORMATION
The results of any genetic test, including genetic test information, shall not be used as the basis to (1) terminate, restrict, limit or
otherwise apply conditions to the coverage of an individual or family member under the plan, or restrict the sale of the plan to an
individual or family member; (2) cancel or refuse to renew the coverage of an individual or family member under the plan; (3) deny
coverage or exclude an individual or family member from coverage under the plan; (4) impose a rider that excludes coverage for
certain benefits or services under the plan; (5) establish differentials in monthly costs or cost-sharing for coverage under the plan;
(6) otherwise discriminate against an individual or family member in the provision of insurance.
SIGNATURE REQUIREDEMPLOYEE AGREEMENT
I declare all statements contained in this entire form are true and correct and that no material information has been withheld or omitted.
I understand and agree that the Plan Sponsor is not bound by any statement made by or to any agent unless written herein. I agree that
no medical benefits will be effective until the date specified in the Summary Plan Description. If I am now waiving medical coverage
for myself and/or for my dependents, I have read the entire Waiver provision and understand the enrollment requirements if I make a
request for such coverage at a later date.
Coverage is effective only after approval and satisfaction of any probationary period.
In some states, any person who, knowingly and with intent to defraud an insurance company or plan administrator, submits an enrollment
form or files a claim containing any materially false information may be guilty of fraud, which is a crime.
All pages must be attached and complete, including this authorization, for the enrollment form to be considered complete. Incomplete
enrollment forms may be rejected.
Enrollee Signature X_____________________________________________________________ Date (required)________________
If signed by a representative of enrollee, please indicate the representatives legal authority to act on behalf of enrollee.
___________________________________________________________________________________________________________
Page 3 of 4
EE-AP-202-0713
SIGNATURE REQUIRED AUTHORIZATION TO USE MEDICAL INFORMATION FOR ENROLLMENT
I hereby authorize those physicians, medical practitioners, hospitals, clinics, veterans administration facilities, pharmacy benefit managers,
medical information services, urgent care facilities, and other medical or medically related entities, insurance or reinsurance companies,
and consumer reporting agencies that have information available as to the present or former physical health condition, including drug
or alcohol abuse, and/or treatment of me or my dependents proposed for coverage to release any and all such information, including,
but not limited to, medical records, health care provider notes, laboratory tests and results, diagnoses, treatment, and prognoses. I
understand the information obtained by use of this authorization may be used to determine eligibility for issuance of health coverage for
me and my dependents. This authorization is not applicable to psychotherapy notes.
I agree that a photographic copy of this authorization shall be as valid as the original and that this authorization shall expire 15 months
after the termination of any coverage I obtain. I understand that I may request a copy of this authorization. I understand that I may revoke
this authorization at any time in writing unless action has been taken in reliance on my authorization. Any information obtained will not be
released to any person or organization, except to reinsuring companies or other persons or organizations performing business or legal
services in connection with my enrollment for the coverage, for any claim, for medical management purposes, or as may be otherwise
lawfully required or as I may further authorize.
Enrollee Signature X_________________________________________________________________________ Date_____________
If signed by a representative of enrollee, please indicate the representatives legal authority to act on behalf of enrollee.
___________________________________________________________________________________________________________
Page 4 of 4
EE-AP-202-0713
2013 United HealthCare Services, Inc.
UHCEW646682-000
