Health Insurance Form

"*" indicates required fields

Insurance Forms

GPH Services is offering Health insurance through Health Choices. GHP will pay half of the employee portion only. Dental and Vision are also offered through Humana, however this is at the employee’s expense. Brockman does not contribute to the dental and vision. Please see below break down of your weekly portion. Circle the plan you would like to participate in.

Health Insurance Plan*

*If you choose NOT to enroll for health insurance currently, please still return the paperwork with a signature and date on the last page. If you do not want to sign up for health insurance, then please select the option below to waive all of the health insurance coverage options.

Dental and Vision Insurance Form

GPH Services is offering Dental & Vision insurance for eligible employees. This plan is completely out of the employee’s pocket, GPH does not pay a portion of these benefits. Please see below break down of your weekly portion.

Humana PPO Dental*

Employee: $3.98

Employee/Spouse: $7.96

Employee/Children: $10.15

Family: $14.13

Waive Dental Insurance

Humana Vision*

Employee: $1.44

Employee/Spouse: $2.87

Employee/Children: $2.73

Family: $4.29

Waive Vision Insurance

If you choose NOT to enroll for health insurance currently, please still return the paperwork with a signature and date on the last page.

If you do not want to sign up for dental or vision insurance, then please select the option(s) below to waive all of the dental and vision insurance coverage options.

First Name*

Last Name*

Middle Initial

Home Phone*

SSN#*

Date of Birth*

Height*

Weight*

Gender*

Marital Status*

Single

Married

Hidden

Group Number

Hidden

Employer Name*

Hidden

Employer Location (If more than one)

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

County*

Date Employed FT*

Hours Worked / Week*

Occupation - Are you an independent Contractor?*

Yes

Waiver (Please complete if you are declining medical coverage)

Only select the following boxes if you have selected the 'Waive Health Insurance' option above.

Please Check all that apply - I waive medical coverage for:

Employee

Spouse

Child(ren)

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 coverage, 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. I further understand that if I am considered a late enrollee, I may be declined from coverage or excluded from coverage for a period of time as defined in and where permitted by law, and I may be required to provide, where allowed by law, Medical History satisfactory to the Plan Sponsor or Administrator, for myself and/or my dependents.

Family Information (Only for those applying)

Spouse and Children

None

Spouse

Spouse and One Child

Spouse and Two Children

Spouse and Three Children

Spouse and more than Three Children

Spouse Information

Spouse Name

First Name & Middle Initial and Last name (If different)

Date of Birth

Social Security Number

Height

Weight

Physician's Name

Gender

Child 1

Child Name

First Name & Middle Initial and Last name (If different)

Date of Birth

Social Security Number

Height

Weight

Primary Care Physician's Name

Gender

Child 2

Child Name

First Name & Middle Initial and Last name (If different)

Date of Birth

Social Security Number

Height

Weight

Primary Care Physician's Name

Gender

Child 3

Child Name

First Name & Middle Initial and Last name (If different)

Date of Birth

Social Security Number

Height

Weight

Primary Care Physician's Name

Gender

For more than three children - enter the Name, Birth date, SSN, Height, Weight, Gender and Physician's name for remaining children.

Eligibility and other insurance information

Are you currently working full-time?*

Yes

If no, please explain.

Do you or any family members intend to keep other insurance coverage in addition to this coverage?*

Yes

If yes, list family members:*

List the name of other insurance companies and the policy numbers:

List family members covered by Medicare and their effective date:

Coverage and Change Request Information

Only select the following boxes if you have had a change in your family or marital status from the previous year.

Change for:

Employee

Family

Employee\Spouse

Employee / Children

Name of Medical plan & PPO Network Selected:

Change Request:

Marriage

Divorce

Adoption

Court Ordered

Date of event (Proof may be required)

Required Medical Information

Provide details to “Yes” answers including information regarding last doctor visit and/or physical examination and all medications taken (attach extra pages if needed with signature and date.)

Within the past two (2) years, have you or any eligible dependent been diagnosed; had symptoms; had testing completed; had treatment; tested positive for; taken medications; or received routine follow up or consultation for any of the following: Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC), HIV, Cancer/Tumor, Diabetes, Heart/Blood/Vascular Disorder/Hypertension, Kidney Disorder, Liver Disorder, Hepatitis, Respiratory/Lung Disorder, Stroke, Systemic Lupus/Multiple Sclerosis, Organ/Tissue Transplants, Immune System Disorder, Mental Disorder, Alcohol/Drug Abuse, Neurological Disorder, Birth Defects/Congenital Disorder, Arthritis/Back/Joint Disorder, or Infertility?*

Yes

Hidden

Question 1

Name*

Illness / Impairment*

Dates Treated*

Medications / Treatment / Surgery / Treating Physician*

Are you or any dependent disabled; hospital confined; pregnant; receiving treatment; taking medication; receiving follow up care; been scheduled for or are awaiting results of any tests, biopsies, procedures or lab work; or been advised of a condition that will require attention in the next 24 months?*

Yes

Hidden

Question 2

Name*

Illness / Impairment*

Dates Treated*

Medications / Treatment / Surgery / Treating Physician*

TO BE A VALID APPLICATION, YOUR SIGNATURE AND THE DATE YOU SIGN IT ARE REQUIRED. SIGNATURE REQUIRED – EMPLOYEE AGREEMENT

I understand that the previous answers will be relied upon by the Plan Sponsor in the issuance of a Summary Plan Description. I declare all statements contained in this entire form about me and my dependents are true and correct to the best of my knowledge and that no material information has been withheld or omitted. I understand that my intentional misrepresentation of a material fact or my failure to report information about me or my dependents may be used as the basis to rescind, terminate or modify coverage for me or my dependents. Rescind means that the coverage was never in effect. 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 coverage will be effective until the date specified by the Plan Sponsor in the Summary Plan Description. The actual effective date may not be the requested effective date. If I am now waiving medical benefits for myself and/or my dependents, I have read the entire Waiver provision and understand the enrollment requirements if I make request for such benefits at a later date.

To assist with determining my creditable coverage, I authorize any insurance company, third party administrator, or other carrier or provider of health benefits to release to the third party administrator and/or Plan Sponsor certificates of creditable coverage and all such information.

I authorize my employer to deduct the necessary contribution toward the benefits. I reserve the right to revoke this deduction authorization at any time upon my written notice. Benefits are effective only after approval by the Plan Sponsor or Administrator and satisfaction of any probationary period. Any person who knowingly and with intent to defraud, submits an application or files a claim containing any materially false information may be found guilty of fraud, which is a crime, in a court of law and may be subject to fines and confinement in prison. This will not be considered as a complete application unless all pages are attached and completed.

Untitled*

I understand that information on this application is valid for a maximum of 60 days from the date of signature.

Applicant Signature (Type full name)*

Date*

If signed by a representative of applicant, please indicate the representative’s authority to act on behalf of applicant.

SIGNATURE REQUIRED/AUTHORIZATION TO RELEASE MEDICAL INFORMATION FOR ENROLLMENT

I also hereby authorize any physician, medical practitioner, hospital, clinic, Veterans administrations facility, other medical or medically related facility, insurance or reinsurance company, pharmacy, pharmacy benefit manager, health plan, or Consumer Reporting Agency, having information available as to diagnosis, treatment and prognosis with respect to any physical or mental condition, including drug or alcohol abuse, and/or treatment of me or my minor children and other non-medical information of me and my minor children, to release to the claims or third party administrator, any other excess loss insurance carrier designated by the Plan, or its legal representative, any and all such information as required for determination of eligibility for benefits. I also understand that my dependents of legal age, in order to be eligible for benefits, may be required to sign a similar release of medical records for the purpose of determining the accuracy of statements made by me on this application and for the ultimate determination of eligibility for benefits under the Plan. I understand that I may request a copy of this authorization at any time. I understand that any information that is disclosed pursuant to this authorization may be re-disclosed and no longer covered by federal rules governing privacy and confidentiality of health information.

I agree that a photographic copy of this authorization shall be as valid as the original, and that this authorization shall be valid for 2 ½ years from the date shown below. I understand the information obtained by use of this authorization may be used by the Plan Sponsor, claims or third party administrator, and any excess loss insurance carrier designated by the Plan to determine eligibility for health coverage, and eligibility for benefits under an existing plan, for myself and my dependents. 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. I also understand that I have a right to revoke this authorization in writing at any time, except to the extent information has been released in reliance upon this authorization. Should I refuse to sign this authorization, I understand it may affect my enrollment in the benefit plan. All pages must be attached and complete, including this authorization for the application to be considered complete. Incomplete applications may be rejected.

Applicant Signature (Type full name)*

Date*

If signed by a representative of applicant, please indicate the representative’s authority to act on behalf of applicant.

Email*