United Employee Enrollment Form Details

United Health Care is a large company that provides health insurance to individuals and families. If you are a United Health Care customer, there may come a time when you need to fill out a form. In this blog post, we will provide an overview of the United Health Care form, including what information is required and how to submit it.

Here is the data in regards to the file you were seeking to fill in. It can show you how much time it will require to finish united health care form, exactly what fields you will have to fill in, and so on.

QuestionAnswer
Form NameUnited Health Care Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesunitedhealthcare enrollment form 2020, united healthcare application form, united healthcare employee enrollment form, uhc enrollment form

Form Preview Example

(DO NOT STAPLE)

Employee Enrollment Form

UnitedHealthcare Insurance Company

 

UnitedHealthcare of Texas, Inc.

 

National Pacific Dental, Inc.

To speed the enrollment process, please be thorough and fill out all sections that apply.

Unimerica Insurance Company

PacifiCare Life & Health Insurance Company

 

Gr up Name

 

 

 

 

 

Requested Effective Date of Coverage/Date of Change

/

/

 

 

To Be Completed by Employer

 

 

Group Name/Policy Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Hire

 

/

 

/

 

 

 

 

 

Reason for Application

 

 

 

 

 

Employee Type

 

 

Position/Title

 

 

 

 

 

 

 

 

 

New Group Plan

New Hire

 

 

(Check all that apply)

 

 

 

 

 

 

 

 

 

 

 

 

Life Event/Date_______

Annual

 

 

Active

COBRA State Continuation

 

 

 

 

 

 

 

 

 

 

 

 

Status Change_______

Open

 

 

 

 

Start dt ____/____/____

 

 

Hours Worked per week

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dependent Add/Delete

Enrollment

 

 

 

End dt____/____/____

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Change Name/Address

Late

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hourly

Salary

 

 

Salary $______ Required only if Life, STD, or LTD

 

Waiving Coverage

Enrollee

 

 

 

 

 

 

 

Union

Non-Union Retired

 

 

 

Termination

 

 

 

 

 

 

 

 

 

Plan based on salary

 

 

 

 

 

 

 

 

 

Other ____________________________

 

 

 

 

 

 

 

 

Other _________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A. Employee Information

If you are waiving all coverage, please complete sections A and G.

 

 

Last Name

 

 

 

 

 

First Name

 

 

MI

Social Security Number

 

Home/Cell Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Work Phone

 

 

Address

 

 

 

 

 

Apt #

City

 

 

 

State

 

Zip Code

 

Language preference, if not English

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Birth

 

 

Sex

 

Height

 

Weight

 

Used tobacco in the last

 

Email Address

 

 

 

/

/

 

M

F

 

 

 

 

 

 

12 months? Yes No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Marital Status

Single Married

Divorced Widowed

Physician* (First & Last Name)/ ID #

Primary Care Dentist** (First & Last Name)/ ID #

Do you have a disability affecting your ability to communicate or read? Yes No

HMO female enrollees are not required to select an obstetrician or gynecologist. Obstetrical or gynecological care can be received from her primary care physician, primary care provider or an obstetrician or gynecologist.

 

B. Family Information

 

 

List All Enrolling (Attach sheet if necessary)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last Name

First Name

MI

Sex

Relationship***

Birthdate

Height

Weight

Physician* (Name/ID#)

Tobacco

Social Security Number

 

 

 

 

 

 

Primary Care Dentist** (Name/ID#)

Used

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

Spouse

 

 

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

F

 

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

Dependent

 

 

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

F

 

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

Dependent

 

 

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

F

 

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

Dependent

 

 

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

F

 

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*Important: For UnitedHealthcare products requiring you to choose a Primary Care Physician, you must use the UnitedHealthcare directory of providers to choose a Primary Care Physician for yourself and each of your covered dependents. **Please see employer representative as some dental plans require a Primary Care Dentist (PCD) selection. ***For court ordered dependent, legal documentation must be attached. If dependent does not reside with eligible employee, please provide address on a separate sheet.

Coverage Provided by “UnitedHealthcare and Affiliates”:

Medical coverage provided by UnitedHealthcare Insurance Company (PPO, indemnity), UnitedHealthcare of Texas, Inc. (HMO), or PacifiCare Life & Health Insurance Company (PPO, Indemnity)

Dental coverage provided by UnitedHealthcare Insurance Company (indemnity), National Pacific Dental, Inc. (HMO) or Unimerica Insurance Company (indemnity) Life, Short-Term Disability (STD), Long-Term Disability (LTD) insurance coverage provided by UnitedHealthcare Insurance Company or Unimerica Insurance Company

Vision coverage provided by UnitedHealthcare Insurance Company (PPO, indemnity) or Unimerica Insurance Company (PPO, indemnity)

SB.EESHT.10.TX 6/10

Page 1 of 4

275-4229 3/11

Employee Name __________________________________________________________________________________________________________

Please check the box for each coverage you or your dependents are enrolling in.

C. Product SelectionIf your employer offers a choice of plans, indicate which plan you are selecting. Indicate the dollar amount selected for the Life and Accidental Death & Dismemberment (AD&D), Supplemental Life, Short-Term Disability

(STD), and Long-Term Disability (LTD) plans. Benefit offerings are dependent upon employer selection.

Person

 

Medical

Dental

Vision

Basic Life/AD&D

Supp Life/AD&D

 

Employee

_____________

_____________

$_____________

$_____________

 

Spouse

$_____________

$_____________

 

Dependent

$_____________

$_____________

 

 

 

 

 

 

 

 

 

Person

 

STD

STD Buy Up

LTD

LTD Buy Up

 

 

Employee

$_____________

$_____________

$_____________

$_____________

 

 

 

 

 

 

 

 

 

 

Life Insurance Beneficiary’s Full Name and Address

 

 

Relationship

 

 

 

 

 

 

 

 

 

 

D. Prior Medical Insurance Information This section must be completed to receive credit for prior medical coverage.

Within the last 12 months, have you, your spouse, or your dependents had any other medical coverage?

NO YES (if yes, please complete this section.)

Prior medical carrier name ____________________________________________________ Effective date ___/___/___ End date ___/___/___

Prior coverage type: Employee

Spouse

Child(ren)

Family

 

 

 

 

E. Other Medical Coverage Information This section must be completed. (Attach sheet if necessary.)

On the day this coverage begins, will you, your spouse or any of your dependents be covered under any other medical health plan or policy, including another UnitedHealthcare plan or Medicare? YES (continue completing this section) NO (skip the rest of this section)

Name of other carrier ______________________________________________________

Other Group Medical Coverage Information

Type

Effective Date

End Date

Name and date of birth of policyholder

(only list those covered by other plan)

(B/S/F)*

MM/DD/YY

MM/DD/YY

for other coverage

 

 

 

 

 

Employee:

 

 

 

 

 

 

 

 

 

Spouse Name:

 

 

 

 

 

 

 

 

 

Dependent Name:

 

 

 

 

 

 

 

 

 

Dependent Name:

 

 

 

 

 

 

 

 

 

Dependent Name:

 

 

 

 

 

 

 

 

 

*B. Enter ‘B’ when this dependent is covered under both you and your spouse’s insurance plan (married)

S. Enter ‘S’ if you are the parent awarded custody of this dependent and no other individual is required to pay for this dependent’s medical expenses. F. Enter ‘F’ if this dependent is covered by another individual (not a member of your household) required to pay for this dependent’s medical expenses.

Medicare – Employee Information:

If enrolled in Medicare, please attach a copy of your Medicare ID card.

Enrolled in Part A: Effective Date _____________

Ineligible for Part A*

Not Enrolled in Part A (chose not to enroll)**

Enrolled in Part B: Effective Date _____________

Ineligible for Part B*

Not Enrolled in Part B (chose not to enroll)**

Enrolled in Part D: Effective Date _____________

Ineligible for Part D*

Not Enrolled in Part D (chose not to enroll)**

Reason for Medicare eligibility: Over 65

Kidney Disease

Disabled

Disabled but actively at work

Are you receiving Social Security Disability Insurance (SSDI)? YES

NO Start Date ___ /___ /___

 

Medicare – Spouse/Dependent Name: ____________________________________________

Enrolled in Part A: Effective Date _____________

Ineligible for Part A*

Not Enrolled in Part A (chose not to enroll)**

Enrolled in Part B: Effective Date _____________

Ineligible for Part B*

Not Enrolled in Part B (chose not to enroll)**

Enrolled in Part D: Effective Date _____________

Ineligible for Part D*

Not Enrolled in Part D (chose not to enroll)**

Reason for Medicare eligibility: Over 65

Kidney Disease

Disabled

Disabled but actively at work

*Only check “Ineligible” if you have received documentation from your Social Security benefits that indicate that you are not eligible for Medicare.

**If you are eligible for Medicare on a primary basis (Medicare pays before benefits under the group policy), you should enroll in and maintain coverage under Medicare Part A, Part B, and/or Part D as applicable.

Page 2 of 4

H. Signature

F. Medical History

Employee Name ____________________________ SSN _____________________ Group Name __________________________________

Please answer the following questions for yourself and each person listed in Section B “Family Information” on the first page of this form. Please answer completely and truthfully. Please note that, if you leave out or misrepresent information, we may terminate or not renew your coverage, or we may change your premium retroactive to the date your policy became effective. UnitedHealthcare is only seeking to collect information about the current health status of those persons listed on the application. In answering these questions, you should not include any genetic information. Please do not include any family medical history information or any information related to genetic services or genetic diseases for which you believe you or your dependents may be at risk.

Yes

No

1.

Is anyone on this application currently pregnant? If “yes” please provide detailed information including anticipated delivery

 

 

 

date, any pregnancy complications, anticipation of multiple births, and/or Cesarean Section.

 

 

 

 

Yes

No

2.

Has anyone on this application visited any health care professional during the last 5 years for any illness, injury, or health

 

 

 

condition? If your answer is "yes" please provide detailed information on next page for each person involved.

 

 

 

 

Yes

No

3.

Has anyone on this application been hospitalized (inpatient or outpatient) or had surgery in the past 12 months? If your

 

 

 

answer is “yes” please provide detailed information on next page for each person involved.

Yes

No

4.

Has anyone on this application been prescribed or taken any prescription medications in the past 12 months? If your

 

 

 

answer is “yes” please provide detailed information on next page for each person involved.

 

 

 

 

Yes

No

5.

Does anyone on this application have a health condition, illness, or injury that may require treatment or surgery, or has any

 

 

 

health care professional recommended treatment or surgery for any of you that has not been performed? If your answer to

 

 

 

either question is “yes” please provide detailed information below for each person involved.

Please give details of all “yes” answers above. (If additional space is required, please attach a separate sheet and be sure to date and sign that sheet.)

Question #

Person

Condition/Diagnosis

Treatment/Meds

Physician’s Name

Dates Treated

Prognosis

G. Waiver of Coverage

I decline all coverage for:

Myself

Spouse

Dependent Children

Myself and all dependents

Declining coverage due to existence of other coverage:

Spouse’s Employer’s Plan

Individual Plan

Covered by Medicare

Medicaid

COBRA from Prior Employer

VA Eligibility

Tri-Care

I (we) have no other coverage at this time

Other ____________________________________

I understand that by waiving coverage at this time, I will not be allowed to participate unless I qualify at a special enrollment period or as a late enrollee, if applicable, or at the next open enrollment period. I also understand that pre-existing limitations may apply as explained in the Rights and Responsibilities brochure which I have received with this form.

Date

Employee Signature if waiving coverage

I authorize UnitedHealthcare Insurance Company and its affiliates ("UnitedHealthcare and Affiliates") to obtain, use and disclose my medical, claim or benefit records, including any individually identifiable health information contained in these records. I understand these records may contain information created by other persons or entities (including health care providers) as well as information regarding the use of drug, alcohol, HIV/AIDS, mental health (other than psychotherapy notes), sexually transmitted disease and reproductive health services. I authorize any health care provider, pharmacy benefit manager, other insurer or reinsurer, hospital, clinic or other medical facility, health care clearinghouse, and any of their affiliates, representatives or business associates, to disclose my information to UnitedHealthcare and Affiliates. I understand the purpose of the disclosure and use of my information is to allow UnitedHealthcare and Affiliates to make decisions regarding eligibility, enrollment, underwriting and premium risk rating. I understand this authorization is voluntary and I may refuse to sign the authorization. My refusal may, however, affect my ability to enroll in the health plan or receive benefits, if permitted by law. I understand I may revoke this authorization at any time by notifying my UnitedHealthcare and Affiliates representative in writing, except to the extent that action has already been taken in reliance on this authorization. As required by HIPAA, UnitedHealthcare and Affiliates also request that I acknowledge the following, which I do: I understand that information I authorize a person or entity to obtain and use may be re-disclosed and no longer protected by federal privacy regulations. This authorization, unless revoked earlier, expires 30 months after the date it is signed.

I understand that I am completing a joint life and health application and that each response must be complete and accurate. I (we) request the indicated group medical coverage for myself and, if the plan provides, for my dependents. I authorize any required premium contributions to be deducted from earnings. I (we) have not given the agent or any other persons any health information not included on the application. I (we) understand that UnitedHealthcare and Affiliates is not bound by any statements I (we) have made to any agent or to any other persons, if those statements are not written or printed on this application and any attachments. I have a continuing obligation to report changes in health status (e.g. received medical advice, diagnosis, care or treatment) after I sign the enrollment form and before receipt of my identification card. Please maintain a copy of this authorization for your records.

Date

Employee Signature for all applying

Spouse Signature (if applying for coverage)

Page 3 of 4

I. Census Information (optional)

NOTE: Responding to this question is optional and is not required. Data collected in this section will be used only to help communicate with enrollees and inform them of specific programs to enhance their well-being. This information will not be used in the eligibility process.

1.

Race, check all that apply:

White Black, African-American

American Indian/Alaska Native

Asian

 

 

Native Hawaiian/Pacific Islander

Other Race, please specify_______________________

 

 

 

 

2.

Are you of Hispanic or Latino origin? Yes No

 

 

 

 

 

 

 

Page 4 of 4