hsainsurance.com
New Group Submission Checklist
NEIGHBORHOOD HEALTH PLAN
To ensure your application is processed as quickly and accurately as possible, follow these steps:
1.
The employer completes and signs the HSA Membership Application
2.
The employer completes and signs the Group Enrollment Application
3.
The employer must provide a copy of the present carrier’s current premium statement
4.
Provide a copy of the following information:
If a sole Proprietorship
 Wage Detail Report from DUA QUEST
System/WR-1 Mass. Quarterly Payroll
(if filed)
If a Corporation or Partnership
 Wage Detail Report from DUA
QUEST System/WR-1 Mass.
Quarterly Payroll (most recent)
 1040 Schedule C
If a New Business
 If tax information is not available,
owner must provide copies of DBA
Certificate, Business License,
Articles of Incorporation or other
proof deemed appropriate by NHP
5.
Each eligible employee completes a NHP Enrollment and Change Form including its choice of NHP Primary Care
Physician for each family member.
6.
Each eligible employee applying for a waiver completes a Waiver of Coverage Form.
7.
Enclose copy of Proposal/Quote showing rates for desired effective date
8.
Pay your first premium:
 Pay over the phone: (781) 228-2222. Payment Confirmation #:__________________________
-or Complete Electronic Payment Request Form
-or Enclose check payable to Health Services Administrators (HSA)
(Receipt of payment does not guarantee coverage. HSA must receive completed enrollment materials by the carrier deadline)
9.
Enclose your Annual Membership Fee of $125 (payable to HSA), (see step 8).
-orIf enrolling through an Association or Chamber of Commerce, please note the name:
_________________________________________________________________
(If not already a member of a participating Association or Chamber of Commerce, additional requirements may apply, such as
completing a membership application and paying dues.)
10.
Send all required documents (including this checklist) to:
Corporate Office
135 Wood Road
Braintree, MA 02184
-or-
Regional Office
574 Boston Road
Billerica, MA 01821
Sales Rep:
Contact Info:
PLEASE NOTE: Complete applications and premium payment for new business must be received by HSA at least 5 business
days prior to the requested effective date.
All coverage will be effective on the 1st day of the month. Once your enrollment has been approved and processed, you will receive a
member confirmation by mail with your account number. Your permanent ID cards will be issued to you directly by the carrier.
Permanent ID cards generally take 7-10 business days from date your enrollment was approved and processed.
Corporate Office: 135 Wood Rd, Braintree, MA 02184 | (781) 848-4950 | (877) 777-4414 | (781) 848-7020 fax
2015
hsainsurance.com
Membership Application
Please complete each section of this application. Failure to do so could delay enrollment.
Employer information
Employer name____________________________________________________ Date business established (Mo./Yr.) _____/_______
Employer address ______________________________________________________________________________________________
City _________________________________________________________State __________________ Zip ______________________
Owner/principal contact name (first and last) ____________________________________ Title_________________________________
Business Phone ________________________ Cell phone _________________________ Fax _______________________________
Email _________________________________________________________ Website _______________________________________
Billing address ________________________________________________________________________________________________
City___________________________________________________________State _________________ Zip ______________________
Type of business  Corporation  Partnership
 Proprietorship  LLC  Other: ________________________________
Nature of business: _____________________________________________________________________________________________
Employer tax ID# _________________________________________________ SIC code_________________________
Do you regularly employ at least one individual that is not an owner and/or the spouse of an owner? Yes
 No
Number of full-time employees (30 hours or more per week; including owner) ____________
Number of part-time employees (less than 30 hours per week) _____________
Quote # (from Group Proposal) ____________________________________________
Certification
1.
2.
3.
4.
5.
6.
7.
8.
9.
The company named above is a bona fide business and not in operation for the sole purpose of obtaining health insurance.
All enrollees are actively working for financial compensation and are covered by Worker’s Compensation as required by law.
Premium payments are due on the 25th of each month for coverage effective the 1st of the next month.
Insurance coverage is subject to cancellation if payments are not received by the 1st of the month.
Payments not received by the 10th of the month are subject to a late fee, currently $25.
Payments not received by the 20th of the month are subject to a pending termination fee, currently $50.
Reinstatement of coverage terminated due to non-payment of premium is at the sole discretion of the carrier.
Checks returned for insufficient funds or other reasons will be charged a bad check fee, currently $20.
Member firms must maintain good standing in their respective Business Association or Chamber of Commerce to participate in the group
insurance programs offered through HSA.
10. HSA Insurance is a billing and enrollment agent and is not responsible for payment of claims on your behalf.
I certify that the information on this form is true and complete, that I understand and agree to the above administrative requirements, and that I
have the legal authority to sign on the company’s behalf.
Signature ______________________________________________ Title _________________________________ Date ____________
Broker name (if applicable) __________________________________________________________________________________________
Address _________________________________________________________________________________________________________
City ________________________________________________________ State __________________________ ZIP ________________
For office use only
Account representative ___________________________________________________________
Corporate Office: 135 Wood Rd, Braintree, MA 02184 | (781) 848-4950 | (877) 777-4414 | (781) 848-7020 fax
2014
hsainsurance.com
Group Enrollment Form
Neighborhood Health Plan
Company Name:
Desired Effective Date:
Plan Selection:
NHP Prime HMO 3000/6000 25/40 FlexRx 4-Tier
NHP Prime HMO 2000/4000 30/50 - 35% FlexRx 4-Tier
NHP Prime HMO HSA 2500/5000 FlexRx 4-Tier
NHP Prime HMO HSA 2000/4000 FlexRx 4-Tier
NHP Prime HMO 1750/3500 50/75 FlexRx 4-Tier
NHP Prime HMO 2000/4000 25/40/150 FlexRx 4-Tier
NHP Prime HMO 1500/3000 25/40 FlexRx 4-Tier
NHP Prime HMO 500/1000 20/35 - 30% FlexRx 4-Tier
NHP Prime HMO 1000/2000 25/40/150 FlexRx 4-Tier
NHP Prime HMO 750/1500 30/45 FlexRx 4-Tier
NHP Prime HMO 25/40 FlexRx 4-Tier
SIC Code (4 digits)
Employer Contribution (Must answer both)
Minimum 50% for Ind. and 33% for Family.
Individual _____%
Family _____ %
[___________]
Nature of business:
Eligibility Waiting Period*
 Date of hire
 1st of the month following date of hire
 30 days following date of hire
 1st of the month following 30 days
 60 days following date of hire
 1st of the month following 60 days  90 days following date of hire
*Definition: The period from the date of hire to the time a new employee is eligible to be enrolled in the company health plan.
List ALL full-time employees working 30 or more hours per week (Owners Included)
Name
Date of
Birth
Ind. (I) Two Person (2P)
Employee & Child(ren)
(E+C) Family (F)
Covered by Spouse’s
health plan
YES
Present Carrier/HMO
Name or None
Current
Monthly
Premium
NO
Do you currently have insurance? If Yes, with whom? _______________________________________________________________________
Signature (Authorized Employer Representative)
Title
Date
Corporate Office: 135 Wood Rd, Braintree, MA 02184 | (781) 848-4950 | (877) 777-4414 | (781) 848-7020 fax || Regional Office: 574 Boston Road, Billerica, MA 01821
Rhode Island Office: 2220 Plainfield Pike, Cranston RI 02921 | (401) 942-0966 | (401) 944-3586 fax
Enrollment and Change Form Tel 800-462-5449
HSA,
Wood Road,
Braintree
MA, 02184
253135
Summer
Street,
Boston,
MA
02210-1120 Fax 617-526-1981
Application for Enrollment
 New employee
 Annual enrollment
 COBRA Continuation
 Involuntary loss of prior group coverage*
 Other Please use a ball point pen
and press down firmly.
Tel (800) 696-8167
Fax (781) 848-7020
www.hsainsurance.com
*Documentation required
Change in Enrollment
 Adding dependents
 Deleting dependents
 PCP/Site change
 Termination
 Employee/dependent demographics
 Other Reason for Change in Enrollment
 Marriage
 Adding disabled dependents
 Birth of child
 Moved out of service area
 Adoption of child*  Voluntary
 Divorce
 Loss of dependent eligibility
 Left employment  Death, exact date  Reached age 65
Group Information
NHP group
number
Date of
employment
Employer
name
Month
Day
Year
Effective Month Day
Date
Year
Plan
design
Employee Information
Last name
First name
Date of birth (mm/dd/yy)
Social Security Number
-
Gender (m/f)
Home phone – Include area code
Work phone – Include area code
-
Street mailing address
Apt.
PCP and Site Information
M.I.
P.O. Box
City
State
Zip code
If the Primary Care Physician (PCP) you choose is not in the NHP network, one will be selected for you. For help finding a PCP, please go to nhp.org and use
our Provider Search Tool under the “Find a Provider” link. You may change your PCP assignment at any time.
Primary
care site
Your Primary Care Physician
(Last name, First, M.I.)
Existing patient?
 Yes
 No
Language
What language do you speak most often? Please check () the appropriate box. Knowing the main language spoken by you and your family members will help us to better serve your needs.
English (04) Spanish (14) French (05) Haitian Creole (06) Portuguese (12) Russian (13) Cape Verdean Creole (03) Cantonese (02) Mandarin (11) Vietnamese (15) Other (16), please specify
Group Coverage
Type of NHP coverage (check only one)
In addition to NHP, my spouse or children are covered by a health plan offered by:
 Self  Individual & spouse  Individual & child/children  Family
Employer
Are you and/
or your spouse
eligible for
Medicare?
Insurance co. name
Self
 Yes
 No
If yes, are you enrolled in
 Medicare Part A
 Medicare Part B
Spouse
 Yes
 No
If yes, is your spouse enrolled in
 Medicare Part A
 Medicare Part B
Policy #
Effective date
Your Medicare
policy number
Your spouse’s
Medicare policy number
Please provide ALL information below for any eligible dependents you wish to enroll.
Spouse last name
First name
Social Security Number
-
Date of birth
Dependent last name
Dependent last name
Dependent last name
Dependent last name
Date of birth
Gender (m/f)
Gender (m/f)
Gender (m/f)
Other Insurance?
 Yes
Gender (m/f)
 No
M.I.
Other Insurance?
 Yes
 No
M.I.
Other Insurance?
 Yes
First name
Social Security Number
-
 No
M.I.
First name
Social Security Number
-
Date of birth
 Yes
First name
Social Security Number
-
Date of birth
Other Insurance?
First name
Social Security Number
-
Date of birth
Gender (m/f)
M.I.
 No
M.I.
Other Insurance?
 Yes
 No
Primary care site
Primary care physician (last name, first name, M.I.)
Primary care site
Primary care physician (last name, first name, M.I.)
Primary care site
Primary care physician (last name, first name, M.I.)
Primary care site
Primary care physician (last name, first name, M.I.)
Primary care site
Primary care physician (last name, first name, M.I.)
Existing
patient?
 Yes
 No
Existing
patient?
 Yes
 No
Existing
patient?
 Yes
 No
Existing
patient?
 Yes
 No
Existing
patient?
 Yes
 No
Acknowledgement: The information supplied on this form is true and complete. I assign benefits to Neighborhood Health Plan (NHP) for the cost of services when the liability for payment is the responsibility of another
plan/HMO, worker’s compensation plan or other coverage. I (we) agree that NHP and its affiliated Health Care Providers, may obtain or release my (our) medical information including medical records, medical coverage
available or other medical data for the purposes of administering benefits, evaluating medical care provided, conducting quality assurance reviews and analysis, conducting medical research, and/or as required by law. I
(we) understand that for NHP coverage to be in effect when medical care supplies are obtained, all care and supplies must be authorized and provided by participating care physicians (as listed above).
Acuerdo: La información proporcionada en esta forma es veraz y completa. Asigno (asignmos) beneficios a NHP por el costo de servicios cuando la responsabilidad del pago sea de otro plan de salud/HMO, plan
de compensación para trabajadores o otro tipo de cobertura. Estoy (estamos) de acuerdo que NHP y sus Proveedores de Cuidado de Salud afiliados puenden obtener o divulger mi (nuestra) información médica,
incluyendo registros medicos, cobertura médica disponible o otra información médica, con el próposito de administrar beneficios, evaluar la attención médica proporcionada, realizar revisiones y análisis de control de
calidad, realizar investigaciones médica y/o cuando es requerida por la ley. Yo entiendo (entendemos) que para que la cobertura de NHP tenga vigencia para la obtención de suministros médicos, toda la atención y
todos los sumistros deben ser autorizados y proporcionados por un medico de cuidado primario paricipante autorizado (segun se indica arriba).
All information must be completed and form signed before processing can begin Employee’s signature: Employer contact
name (please print): Phone: Employer’s signature: Return form to HSA, 135 Wood Road,
Braintree
02184
fax (781) 848-7020.
and Employees
keep
Return
white MA,
original
to Neighborhood
HealthEmployer
Plan — Yellow
copy to should
employer
—copies.
Pink copy to employee
Date: Date: Waiver of Coverage Form
Company Name:
_
Employee Name:
Date of Birth
____ I waive health coverage for myself and dependents (if any).
Reasons for Declining Coverage (check one):
___
___
___
___
___
___
___
___
___
___
___
I am covered through spouse’s employer
I am covered through parent’s health plan
I am 65 or over and covered by Medicare
I am covered by Mass Health
I am covered by another health plan offered by my company
I am covered by another health plan offered by a second employer
I am covered by a veterans program
I am covered by a non-group health plan
I do not wish to participate at this time
Other (must provide details)__________________________________
I live in the town of __________________________that is not in
the health plan service area
Employer Name
Insurance Carrier
____________________
Signature of the Employee
________________
Date
This form may
Be duplicated
_
hsainsurance.com
Electronic Payment Request Form
New clients: Use this form if you wish to authorize HSA to deduct your initial payment and/or monthly payments directly
from your checking account.
Client Information:
Client Name:
6 Digit HSA Member #:
Select payment type:
First month’s payment
Recurring monthly payment
Both first month’s payment and recurring monthly payment
If requesting recurring monthly payments, select date for withdrawals to start. All outstanding balances owed, including
fees, will be transferred at that time.
15th of Current Month
24th of Current Month
15th of Next Month
Bank Information:
24th of Next Month
Bank Name:
Branch:
City:
State:
Zip:
Name on Account:
Routing Number:
Bank Account Number:
Authorization:
I (we) hereby authorize HSA to initiate debit entries for my (our) checking account and the depository named above, hereinafter called
DEPOSITORY, to debit the same to such account. This authorization is to remain in full force and effect until HSA has received written
notification from me (us) of its termination in such time and in such manner as to afford HSA and DEPOSITORY a reasonable opportunity to
act on it. Note: all written debit authorizations must provide that the receiver may revoke the authorization only by notifying the originator in the
manner specified in the authorization.
Authorized Signer
Sign Name
Print Name and Title
Sign Name
Print Name and Title
Authorized Signer
(if more than one
required)
Date:
Client Telephone:
Return Form
Please fax or secure email the completed form to: (781) 848-7020 or [email protected]
For changes to existing bank information, please contact Customer Service: (781) 228-2222.
Corporate Office: 135 Wood Rd, Braintree, MA 02184 | (781) 848-4950 | (877) 777-4414 | (781) 848-7020 fax