Quasi-Utah State Agencies
Medical and Dental
State of Utah
Enrollment
and Change
Form
Medical
and Dental
State
of
Utah
Important Note: Enrollment and Change Form
Public Employees Health Programs
560 East 200 South, Suite 100 / Salt Lake City, Utah 84102-2004
Customer
Service:
801-366-7555Health
/ Toll FreePrograms
800-765-7347
Public
Employees
560
East 200
South, Suite 100 Health
/ Salt Lake Programs
City, Utah 84102-2004
Public
Employees
Customer Service: 801-366-7555 / Toll Free 800-765-7347
Medical and Dental
Changes made on this form will affect your medical, dental and vision coverages
Section A
only. If you need to change other PEHP coverages, please complete the
Important
Note:
appropriate forms for those
plans.
Enrollment
and Change Form
560 East 200 South, Suite 100 / Salt Lake City, Utah 84102-2004
Customer
Service:
Section
A 801-366-7555 / Toll Free 800-765-7347
Changes made on this form will affect your medical, dental and vision coverages
only. If you need to change other PEHP coverages, please complete the
Employee and Coverage Information
PLEASE PRINT CLEARLY
appropriate Note:
forms for those plans.
Important
Changes made on this form will affect your medical, dental and vision coverages
New Enrollment
Change
RequestedInformation
(Please specify type): PLEASE PRINT CLEARLY
Employee
and
Coverage
only. If you need to change other PEHP coverages, please complete the
Section
A
EMPLOYEENew
NAMEEnrollment
(last, first, middle initial) Change
appropriate forms for those plans.
BIRTH DATE (mm/dd/yy)
Requested
(Please
specify
type):
SOCIAL
SECURITY
NUMBER
Employee and Coverage Information
EMPLOYEE NAME (last, first, middle initial)
New Enrollment
MAILING ADDRESS
SOCIAL SECURITY NUMBER
Change Requested
(Please specify type):
CITY / STATE / ZIP
EMPLOYEE
NAME (last, first, middle initial)
MAILING
ADDRESS
EMPLOYER / DEPARTMENT
MAILING ADDRESS
EMPLOYER
/ DEPARTMENT
1
Group Medical (check one)
EMPLOYER /Care
DEPARTMENT
Advantage
Group
Medical
(Check one)
Summit
Care STAR2
Advantage
Preferred
Care
Summit
STAR 2 (Check one)
Group Medical
2
Advantage
STAR
Preferred
STAR2 2
Advantage
2 STAR
Summit
STAR
2
Advantage
Care
Summit STAR
2
Preferred
STAR
Summit
Care
Preferred
STAR2
No medical
coverage
Preferred
Care at this time
PLEASE PRINT CLEARLY
MARITAL
GENDER
STATUS
MARITAL
Single GENDER
Male
STATUS
Married
Female
Single
Male
MARITAL
GENDER
STATUS
1
Married
Female
HIRE
DATE (mm/dd/yy)
Single
1Male
BIRTH DATE (mm/dd/yy)
PRIMARY PHONE
SOCIAL
SECURITY
CITY
/ STATE
/ ZIP NUMBER
BIRTH DATE
(mm/dd/yy)
PRIMARY
PHONE
Did you transfer from another de partment?
Yes
No
CITY / STATE
/ ZIP
What
department?
Did
you transfer
from another
department?
Yes
No
ALTERNATE PHONE
PRIMARY PHONE
ALTERNATE
PHONE
HIRE DATE (mm/dd/yy)
Married
Female
What
department?
COVERAGE TYPE (check one)
COVERAGE
TYPE (check one)
Group Dental (check one)
1
Did you transfer
from another
department?
Employee
only
Traditional
Dental
Employee
only
ALTERNATE
PHONE
HIRE
DATE
(mm/dd/yy)
Yes
No
Group Dental (Check one)
Optical Vision Employee
(Check one)
Employee plus one dependent
Preferred Choice Dental
plus one dependent
What department?
Dental
EmployeeTraditional
plus two or Choice
more dependents
Regence Expressions EyeMed
Dental Full Employee plus two or more dependents
(Check
one)
Group
Dental
Preferred
Choice
Dental
No dental coverageOptical
at this
time
Vision (Check one)
Eyemed
EyeMed Eyewear Only
Regence Expressions Dental
Traditional Choice Dental
Preferred Choice Dental
Regence Expressions Dental
Opticare
Eyemed
OptiCare
Eyewear Only
Opticare
COVERAGE
TYPE (Check
No Vision Coverage
at This one)
Time
OptiCare Full
Advantage Care
COVERAGE TYPE (check one)
Advantage
Utah Basic Plus 3
Summit Care
Summit
Utah
Basic Plus 3
Preferred
Care
Employee only
3
Employee
Only No
Optional
Vision
TYPE (check
one) Full
Preferred
Utah
Basic
Plus
EyeMed
Eyewear
Only
OptiCare
Eyewear
Only
Vision
Coverage at This Time
3 EyeMed EyeMedCOVERAGE
Opticare
E OptiCare
No Vision
coverage
at
thisTYPE
time
COVERAGE
(Check
one)
Advantage
Utah
Basic
Plus Full
Employee
plus one
dependent
Employee plus one dependent
3
Employee plus two or more dependents
SummitTYPE
Utah (check
Basic one)
Plus
COVERAGE
Employee only
Employee
or more
dependents
Employee
Employee
Onlytwo
Employee
plus one dependent
Employee
plusplus
two
or more
dependents
No
dental coverage
this time
Preferred only
Utah Basic
Plus 3Only
Employee
Employee
plus oneat
dependent
No
vision coverage
atdependent
this time
Employee
plus
one
EmployeeTYPE
plus (check
one dependent
Employee plus two or more dependents
COVERAGE
one)
Employee plus two or more dependents
Employee
or had
more
dependents
No dental
this time
1. New
enrollees,plus
ifonly
youtwo
have
previous
health coverage within
the lastcoverage
9 months,atplease
attach a Certificate of Creditable
from your
insurance company.
Employee
No Coverage
vision coverage
at former
this time
No
medical
coverage
at
this
time
2. If you
elect
to
participate
in
the
URS
Health
Savings
Account
(HSA),
you
must
complete
an
enrollment
form
for
that
program
- which will be sent to you after enrollment.
Employee plus one dependent
Employee
plus
twohave
or more
dependents
1. New
enrollees,
if you
had previous
health coverage within the last 9 months, please attach a Certificate of Creditable Coverage from your former insurance company.
2. IfNo
youmedical
elect to participate
coverage in
atthe
thisURS
timeHealth Savings Account ( HSA), you must complete an enrollment form for that program - which will be sent to you after enrollment.
3.Section
Utah Basic B
Plus plans are only available to new hires and members previously enrolled in STAR plans.
1. New enrollees, if you have had previous health coverage within the last 9 months, please attach a Certificate of Creditable Coverage from your former insurance company.
2. If you elect to participate in the URS Health Savings Account ( HSA), you must complete an enrollment form for that program - which will be sent to you after enrollment.
SectionPlus
B plans are only available to new hires and members previously enrolled in STAR plans.
3. Utah Basic
ADDITIONS
Dependent Information
Dependent
Information
Complete
the table below
listing your eligible dependents. If adding a new spouse, please include date of marriage, and copy of marriage
Section
ADDITIONS
certificate.
IfBdependents are stepchildren, natural children not living with both parents, or classified as other relationship please provide supporting
Complete
the table below
listing
your eligible
adding a new
please
include
date of marriage,
and copy
of marriage
documentation,
i.e. divorce
decree,
courtdependents.
orders, birthIf certificate,
etc.spouse,
If you don't
have
supporting
documentation
please
explain in Section D.
Dependent
Information
certificate. If dependents
are stepchildren, natural children not living with both parents, or classified as other relationship please provide supporting
ADDITIONS
documentation,
i.e. divorce
decree,
court
orders,
birth certificate,
etc.aIfnew
you spouse,
don't have
supporting
please
Section D.
BIRTH
DATEincludedocumentation
Complete the table
belowOF
listing
your
eligible
dependents.
If adding
please
date of
marriage,
and explain
copy ofinmarriage
RELATIONSHIP
FULL NAME
DEPENDENTS
MARRIAGE DATE
DEPENDENT
GENDER
COVERAGE DESIRED
TO EMPLOYEE
(last, first, are
middle
initial)
(mm/dd/yy)
SOCIAL
SECURITY
NO. please provide supporting
certificate. If dependents
stepchildren,
natural
children not living with both
parents,
or classified
asDEPENDENT
other
relationship
BIRTH
DATE
Month
Day
Year
RELATIONSHIP
FULL NAME OF DEPENDENTS
MARRIAGE DATE
COVERAGE
DESIRED
documentation,
i.e. divorce
court orders, birth
certificate,GENDER
etc. If you Month
don't have
supporting
documentation
explain
in Section
D.
TO
EMPLOYEE
(last, first,decree,
middle initial)
(mm/dd/yy)
SOCIAL SECURITYplease
NO.
Day
Year
CODE KEY
M
F
s
BIRTH DATE
CODE
KEY
RELATIONSHIP
FULL NAME OF DEPENDENTS
MARRIAGE DATE
DEPENDENT
M
F
s
GENDER
S - LegalTO EMPLOYEE
(last, first, middle initial)
(mm/dd/yy)
SOCIAL SECURITY NO.
M
F
Month
Day
Year
Spouse
S - Legal
M
F
Spouse
CODE
KEY
MM
FF
s
C - Child
M
F
Natural
/
CS- -Child
Legal
MM
FF
Adopted
Natural
/
Spouse
M
F
Adopted
SC - Stepchild
MM
FF
C - Child
SC -Natural
Stepchild
M
F
/
O - Other Adopted
MM
FF
O - Otherin
(Describe
M
F
(Describe
SC
- Stepchild
Section
D) in
MM
FF
Section D)
M
F
O - Other
M
F
in spouse or dependents covered by any other health or dental plan or by Medicare?
Are(Describe
you, your
Yes
No
Section
D) your spouse or dependents covered by any other health or dental plan or by Medicare?
Yes
No
Are
you,
M
F
REMOVALS
REMOVALS
Medical
Dental
Vision
Medical
Dental
COVERAGE
DESIRED Vision
Medical
Dental
Vision
Medical
Medical
Medical
Medical
Medical
Medical
Medical
Medical
Medical
Medical
Medical
Medical
Medical
Medical
Medical
Medical
Medical
Dental
Dental
Dental
Dental
Dental
Dental
Dental
Dental
Dental
Dental
Dental
Dental
Dental
Dental
Dental
Dental
Dental
Vision
Vision
Vision
Vision
Vision
Vision
Vision
Vision
Vision
Vision
Vision
Vision
Vision
Vision
Vision
Vision
Vision
If yes, complete Section C
If yes,
complete
SectionVision
C
Medical
Dental
out the
table belowcovered
if you are terminating
coverage
for dependents
who are no longer
is a result
If yes, complete
SectionofC a
Yes eligible.
No If termination
Are you, your Fill
spouse
orthe
dependents
other health
or dental
plan or by Medicare?
Fill out
table below if you by
areany
terminating
coverage
for dependents
who are no longer eligible. If termination is a result of a
divorce, a copy of your divorce decree is required.
divorce, a copy of your divorce decree is required.
REMOVALS
REASON
FOR TERMINATION
Fill out theTOtable
below ifBEyou
are terminating coverage
for dependents whoREASON
are
no FOR
longer
eligible. If termination APPLICABLE
RELATIONSHIP
DEPENDENTS
NO LONGER
COVERED
DEPENDENT
is APPLICABLE
a resultDATE*
of DATE*
a
TERMINATION
DEPENDENT
RELATIONSHIP
DEPENDENTS TO NO LONGER BE COVERED
(i.e. marriage, divorce,
death, age of 26, etc.)
TO EMPLOYEE
(last,
first, middle
initial)divorce decree isSOCIAL
SECURITY NO.
(i.e. marriage, divorce, death, age of 26, etc.)
divorce,
a copy
of your
required.
Month
Day
Year
SOCIAL
SECURITY NO.
TO EMPLOYEE
(last,
first, middle
initial)
Month
CODE KEY
CODE
KEY
RELATIONSHIP
DEPENDENTS TO NO LONGER BE COVERED
S - Spouse
S - TO
Spouse
EMPLOYEE
(last, first, middle initial)
C - Child
C - Child
Natural
/
Natural
/
CODE
KEY
Adopted
S -Adopted
Spouse
SC - SC
Stepchild
Stepchild
C -- Child
O - Other
O - Other
Natural
(Describe
in /in
(Describe
Adopted
Section
D) D)
SCSection
- Stepchild
O - Other
(Describe
incould
*Applicable
Date
could
date
of marriage,
divorce,
birthday,etc.
etc.
*Applicable
Date
be be
date
of marriage,
divorce,
birthday,
Section D)
Signature required, see Section E.
*Applicable Date
could be date
of marriage,
divorce,
Signature
required,
see
Section
E. birthday, etc.
Signature required, see Section E.
DEPENDENT
SOCIAL SECURITY NO.
REASON FOR TERMINATION
(i.e. marriage, divorce, death, age of 26, etc.)
Effective Date:
Month
QST-E
ST-E
HR Approval:
ST-E
(HR Use Only)
Day
Year
APPLICABLE DATE*
Day
Year
Updated 3-11
4-14
Updated
4 -12
Updated 4 -12
Medical and Dental Enrollment and Change Form (Continued)
Employee Name:
Quasi-Utah State Agencies
Social Security Number:
Section C
Multiple Group Coverage
Complete if you, your spouse or dependents are covered by any other health or dental plan, sponsored by an employer or by
Medicare.
INSURANCE COMPANY/HMO
& PHONE NO.
NAME OF
POLICY HOLDER
POLICY HOLDER
SSN OR POLICY
NO.
EFFECTIVE
DATE
(mm/dd/yy)
TYPE OF
COVERAGE
TYPE OF
POLICY
EMPLOYEE/DEPENDENTS COVERED BY PLAN
(Only First Name is Needed)
MEDICARE
Health
Employee
A
Dental
Retired
A&B
Health
Employee
A
Dental
Retired
A&B
Health
Employee
A
Dental
Retired
A&B
CUSTODY OF CHILDREN
If dependents listed on reverse side are not living with BOTH natural parents, please complete the following:
Who has physical custody of the natural children?
Father
Mother
Please provide names and birth dates of both natural parents.
Mother:
Father:
Name
Who has physical custody of the stepchildren?
Father
Mother
Birth Date
Name
Birth Date
Name
Birth Date
Provide names and birth dates of natural parents of stepchildren.
Mother:
Father:
Name
Birth Date
Section D
Explanations
Section E
Employee Agreement and Signature
Before signing, make sure all applicable sections are complete so your enrollment is not delayed. You may be asked to provide
additional information and or documentation. Please note: It is the employee's responsibility to notify the Public Employees
Health/Dental Program within 60 days of any change affecting dependent eligibility (i.e., birth, marriage, divorce, etc.).
I represent that all information is true and correct. I understand and agree that any false information I provide on this form may, at PEHP's sole discretion,
result in a limitation or termination of my coverage. By signing below I hereby: (1) authorize the deduction of health/dental contributions through the
provisions of IRC Section 125 Flexible Benefits; (2) authorize PEHP/PEDP to release information to health/dental providers, insurance entities, or other
entities necessary to process claims and to administer the Health Plan; (3) certify all dependents listed are eligible for coverage; (4) understand if
PEHP/PEDP is not notified that a dependent is ineligible and subsequent claims are paid, I will be responsible for reimbursement to PEHP/PEDP for any
claims paid in error; (5) agree to the terms and conditions in the PEHP/PEDP Master Policy.
EMPLOYEE SIGNATURE
Please make a copy for your records.
DATE