Document cortlandcountyny_gov_doc_9d71a372bf

Cortland County GROUP BENEFIT PLAN ENROLLMENT FORM PLEASE PRINT ALL INFORMATION  MANAGEMENT  NURSES  GENERAL CSEA  ROAD  DOERC  CORR/CIVILIAN LAST NAME: FIRST NAME: SEX:  MALE  FEMALE MARITAL STATUS:  SINGLE  MARRIED  DIVORCED  LEGALLY SEPARATED SS DATE OF BIRTH DATE OF HIRE EFFECTIVE DATE  ACTIVE (PART-TIME)  ACTIVE (FULL-TIME)  COBRA  RETIRED WITH OUT MEDICARE  RETIRED WITH MEDICARE MEDICARE CLAIM NO. PART A EFF. DATE: PART B EFF. DATE: ADDRESS: STREET CITY, STATE, ZIP COUNTY HOME PHONE EMAIL ADDRESS INDIVIDUAL FAMILY MEDICAL (INCLUDES PRESCRIPTION) DENTAL VISION  Spouse Name (First, Last) Sex Date of Birth Social Security #  Children Name (First, Last) Relationship Sex Date of Birth Social Security # College Name Disabled Y/N? Spouse Information (Only complete if enrolling spouse) Medicare Eligible?  Yes  No Medicare Claim No. Is spouse employed?  Yes  No Enrolled in Group Health Plan?  Yes  No Part A Eff. Date: Type of Coverage: Medical  Dental  Prescription  Vision Part B Eff. Date: Single  Family  Name, Address, and Phone # of Spouse's Employer: Name, Address, and Policy Number of Other Health Insurance Coverage: I AUTHORIZE PAYMENT OF BENEFITS TO ANY DOCTOR, PHYSICIAN OR OTHER PROVIDER FOR SERVICES WHICH HE/SHE MAY RENDER TO ME OR MY FAMILY. I CERTIFY THAT ALL THE ABOVE INFORMATION IS CORRECT TO THE BEST OF MY KNOWLEDGE. I DESIRE TO PARTICIPATE IN THE GROUP MEDICAL PROGRAM. DATE SIGNATURE OF EMPLOYEE