hsainsurance.com
MINUTEMAN HEALTH NH
New Individual Application Checklist
To ensure your application is processed as quickly and accurately as possible, follow these steps:
The Individual completes Individual Enrollment Form and selects a Primary Care Physician for each family
member.
2.
Enroll in a Pediatric Dental Plan. If you are obtaining Pediatric Dental from another source, complete and sign
Pediatric Dental Attestation Form.
3.
Enclose a copy of Proposal/Quote showing rates for desired effective date.
1.
4.
Enclose a copy of the Loss of Coverage letter if enrolling outside of the open enrollment period.
5.
If interested in opening a Health Savings Account, Individual completes the HealthEquity Health Savings Account
enrollment forms.
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)
6.
(Receipt of payment does not guarantee coverage. HSA must receive completed enrollment materials by the carrier deadline)
7.
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 postal mail with your account number. Your permanent ID cards will be issued to you
directly from the carrier. Permanent ID cards generally will arrive within 7-10 business days from the 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
2013
New Hampshire Individual Enrollment Form
Enrollee information
Enrollee name (first and last)
Enrollee address
City
Email
/
DOB
Apt #
SSN
State
Primary language
/
Requested effective date
Primary care provider (PCP) name
/
Phone
-
PCP ID #
/
Sex
ZIP
M
F
-
Mobile Phone
Existing patient
Yes
No
If the PCP you select is not in our network, we will select a PCP we think is right for you. You may change your PCP at any time.
Have you used tobacco products (including cigarettes, cigars, chewing tobacco, snuff, and pipe tobacco) an average of four or more times a week
in the past 6 months? Yes
No
Minuteman Health coverage type (select one)
Self
Individual/Spouse
Individual/Child or Children
Please select the plan in which you wish to enroll:
MyDoc HMO Platinum
MyDoc HMO Silver Care
MyDoc HMO Platinum Extra Value
MyDoc HMO Silver Assistance A
MyDoc HMO Gold Basic 1000
MyDoc HMO Bronze Value
MyDoc HMO Silver Basic
MyDoc HMO Bronze Basic 4500
Family
MyDoc HMO Bronze HSA 5800
MyDoc HMO Bronze 6300
MyDoc HMO Simple Care**
Please provide ALL information below for any eligible dependents you wish to enroll. You can use additional enrollment forms if you need more room:
Spouse name (first and last)
DOB
PCP
name
/
/
Sex
M
F
SSN
-
-
IRS dependent
PCP ID #
Yes
No
Existing patient
Yes
No
Has your Spouse used tobacco products (including cigarettes, cigars, chewing tobacco, snuff, and pipe tobacco) an average of four or more times
a week in the past 6 months? Yes
No
Dependent name (first and last)
DOB
PCP
name
/
/
Sex
M
F
SSN
-
-
IRS dependent
PCP ID #
Yes
No
Existing patient
Yes
No
Has this Dependent used tobacco products (including cigarettes, cigars, chewing tobacco, snuff, and pipe tobacco) an average of four or more
times a week in the past 6 months? Yes
No
Dependent name (first and last)
DOB
PCP
name
/
/
Sex
M
F
SSN
-
-
IRS dependent
PCP ID #
Yes
No
Existing patient
Yes
No
Has this Dependent used tobacco products (including cigarettes, cigars, chewing tobacco, snuff, and pipe tobacco) an average of four or more
times a week in the past 6 months? Yes
No
**MyDoc HMO Simple Care meets the federal definition of a “Catastrophic Plan” and as such is only available to certain qualified individuals. You are eligible to
enroll in MyDoc Simple Care if you and each of your benefits eligible dependents: (1) Are under the age of age 30 prior to the first day of the Policy Year OR (2) Have
received a certification from healthcare.gov that you are exempt from the federal requirement to buy health insurance (the “Individual Mandate”).
I agree that Minuteman Health and its providers may obtain and/or release my/our medical information to administer benefits, evaluate medical care provided,
conduct quality assurance reviews and analysis, conduct medical research, and/or as permitted by state and federal law. I agree to provide Minuteman Health with all
information needed to subrogate a claim. I understand that MHI’s authorization to disclose personal health information shall remain valid for no more than 24
months. I understand that for Minuteman Health coverage to be in effect, all care, supplies, and services must be authorized, and/or provided by in-network
providers. I represent, to the best of my knowledge, that all information on this form is correct and complete. No alteration of any written application for insurance,
by erasure, insertion or otherwise, shall be made by any person other than me without my written consent, and the making of any such alteration without my consent
shall be a misdemeanor.
ALL INFORMATION MUST BE COMPLETED AND SIGNED BEFORE PROCESSING CAN BEGIN.
Signature ________________________________________________________________________________ Date
MHI-IND-EnrollForm-412016
/
/
135 Wood Rd, Braintree, MA 02184 | (781) 952-2080 | (781) 848-7020 fax | minuteman.nfphealth.com
New Hampshire Pediatric Dental Attestation
I acknowledge that my health plan coverage provided by Minuteman Health (the
“Health Plan”) DOES NOT include coverage for pediatric dental services. Pediatric
dental coverage is one of the essential health benefits that are generally required to
be included in health plan coverage according to the Affordable Care Act.
By signing this statement, I am attesting that I understand and acknowledge the
following:
-
-
The Health Plan that I am purchasing DOES NOT include coverage for pediatric
dental services.
Because the Health Plan that I am purchasing does not include coverage for
pediatric dental services, the Health Plan does not include all essential health
benefits.
The failure to purchase coverage that includes all essential health benefits
may have tax consequences for me.
There are exchange-certified, stand-alone dental plans available for sale on the
Federal Marketplace (the “exchange”) and off-exchange.
Signature: _______________________
Print Name: ______________________
Date: ___/___/___
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