HomeMy WebLinkAboutOtay Medical and Dental Enrollment Form- Board*Registered Domestic Partner (RDP). You must attach proof of Domestic Partnership Registration as defined under Section 297 and 299.2 of the California Family
Code.
**For Kaiser Participants only, if you are new to Kaiser and do not have a current provider, you will need to register on kp.org after you enroll to select your provider.
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9/1/2022
Medical and Dental
Enrollment Form
Effective Date:
Group Name: Otay Water District
County: _________
Open Enrollment Add Dependent; Qualifying Event ; Qualifying Event Date _______ _
New Enrollment Other
Delete Dependent
SELECTED COVERAGE (Select one)
Medical
Notes: • HMO Plans are not available for out-of-state participants. • Medicare eligible retirees are only eligible for the Gold PPO or Kaiser Senior
Advantage HMO 15 (KPSA) Plan. • If enrolling in the KPSA Plan, the Medicare participant must also fill out a Kaiser
KPSA enrollment form as well.
Dental Group (Select One)
Group # 00002- RETIREE
Group # 00003- BOARD
COBRA Participant
Blue Shield Access + HMO 15 EE only EE + 1 EE + Family Dental
(Retiree eligibility is based on Retiree Tier)
Dental EE only EE + 1 EE + Family Blue Shield EPO EE only EE + 1 EE + Family
Blue Shield Gold PPO EE only EE + 1 EE + Family
Kaiser HMO 15
(Non-Medicare Participants)
EE only EE + 1 EE + Family
Kaiser Senior Advantage HMO 15
(Medicare Eligible Participants)
EE only EE + 1 EE + Family
Decline Medical Coverage (Please complete the Declination of Coverage Section and attach necessary documentation, if
applicable.)
PARTICIPANT INFORMATION
Last Name First Name M.I. Male
Female
Social Security Number (Required) Birth Date (mm/dd/yyyy) Home Phone: Alternate Phone:
Residence Street Address (No P.O. Box) City State Zip Code
Mailing Street Address City State Zip Code
E-Mail Address: Date Sworn in to Office (mm/dd/yyyy)
(For Board Only)
Retiree Status:
Non-Medicare Retiree
Medicare Retiree
Marital Status:
Single
Married
Registered Domestic Partner (RDP)*
Legally Separated Divorced Widowed
Provider Name
Blue Shield HMO Provider Name Required.**Kaiser HMO Provider Name Only if Existing Patient. Primary Care Physician (PCP Code)
(Required for Blue Shield HMO Only)
Existing Patient? (HMO Only)
Yes No
Medicare: Part A
Part B
Medicare Claim / MIB #
*Registered Domestic Partner (RDP). You must attach proof of Domestic Partnership Registration as defined under Section 297 and 299.2 of the California Family
Code.
**For Kaiser Participants only, if you are new to Kaiser and do not have a current provider, you will need to register on kp.org after you enroll to select your provider.
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9/1/2022
DEPENDENT INFORMATION (Please list all eligible family members to be enrolled. Attach additional sheets if necessary.)
Spouse
RDP*
Add:
Delete:
Medical
Medical
Dental
Dental
Last Name First Name M.I.
Male
Female
Social Security Number (Required) Birth Date (mm/dd/yyyy) Medicare
Part A
Part B
Medicare Claim / MIB #
Residence Street Address (No P.O. Box) Check here if same as participant City State Zip Code
Provider Name
Blue Shield HMO Provider Name Required. **Kaiser HMO Provider Name Only if Existing Patient. Primary Care Physician (PCP Code)
(Required for Blue Shield HMO Only)
Existing Patient? (HMO Only)
Yes No
Son
Daughter
Add:
Delete:
Medical
Medical
Dental
Dental
Last Name First Name M.I.
Social Security Number (Required) Birth Date (mm/dd/yyyy) Overage Dependent Type
Disabled Under age 26
Medicare
Part A
Part B
Medicare Claim / MIB #
Residence Street Address (No P.O. Box) Check here if same as participant City State Zip Code
Provider Name Blue Shield HMO Provider Name Required.**Kaiser HMO Provider Name Only if Existing Patient. Primary Care Physician (PCP Code)
(Required for Blue Shield HMO Only)
Existing Patient? (HMO Only)
Yes No
Son
Daughter
Add:
Delete:
Medical
Medical
Dental
Dental
Last Name First Name M.I.
Social Security Number (Required) Birth Date (mm/dd/yyyy) Overage Dependent Type
Disabled Under age 26
Medicare
Part A
Part B
Medicare Claim / MIB #
Residence Street Address (No P.O. Box) Check here if same as participant City State Zip Code
Provider Name Blue Shield HMO Provider Name Required. **Kaiser HMO Provider Name Only if Existing Patient. Primary Care Physician (PCP Code)
(Required for Blue Shield HMO Only)
Existing Patient? (HMO Only)
Yes No
Son
Daughter
Add:
Delete:
Medical
Medical
Dental
Dental
Last Name First Name M.I.
Social Security Number (Required) Birth Date (mm/dd/yyyy) Overage Dependent Type
Disabled Under age 26
Medicare
Part A
Part B
Medicare Claim / MIB #
Residence Street Address (No P.O. Box) Check here if same as participant City State Zip Code
Provider Name Blue Shield HMO Provider Name Required.**Kaiser HMO Provider Name Only if Existing Patient. Primary Care Physician (PCP Code)
(Required for Blue Shield HMO Only)
Existing Patient? (HMO Only)
Yes No
Son
Daughter
Add:
Delete:
Medical
Medical
Dental
Dental
Last Name First Name M.I.
Social Security Number (Required) Birth Date (mm/dd/yyyy) Overage Dependent Type
Disabled Under age 26
Medicare
Part A
Part B
Medicare Claim / MIB #
Residence Street Address (No P.O. Box) Check here if same as participant City State Zip Code
Provider Name Blue Shield HMO Provider Name Required. **Kaiser HMO Provider Name Only if Existing Patient. Primary Care Physician (PCP Code)
(Required for Blue Shield HMO Only)
Existing Patient? (HMO Only)
Yes No
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DECLINATION OF COVERAGE (Complete this section if medical coverage is to be declined by you or your eligible dependents.)
STOP AND READ CAREFULLY.
SIGN ONLY IF DECLINING COVERAGE FOR YOURSELF AND/OR DEPENDENTS. IF SIGNED IN ERROR, PLEASE
CROSS OUT AND INITIAL.
I understand that I am eligible for medical coverage through Otay Water District. I waive the right to enroll in the medical plan as offered by
Otay Water District for the following persons (please check all that apply below):
I decline Medical coverage for: You may elect to decline coverage if you or your dependents are covered by
another group health insurance plan. Please attach proof of medical
Self Spouse/RDP Child(ren) insurance coverage (i.e. insurance ID cards), if waiving for the first time.
List Dependent Name(s) Waiving Coverage:
Reason for waiver:
I have my own other group coverage
We are covered through my spouse’s employer
My spouse and dependents have other group coverage
Other
For Board of Directors check this box if declining coverage:
I understand that by declining coverage, I will not be eligible for coverage until my employer’s next Open Enrollment period unless I
qualify for coverage due to a HIPAA qualifying event (including getting married, having a child, or involuntarily losing my other
coverage).
For Retirees check this box if declining coverage:
By declining coverage for myself, I understand that I will no longer be eligible to re-enroll in the Medical Plan at any time in the
future (and, accordingly, dependents) per the plan rules of the pooled program that the District belongs to (SDRMA). I
understand I will be declining the retiree medical coverage afforded to me as an eligible retiree of the District. Additionally,
by signing below I certify that the reason I am declining coverage is accurate as indicated by the check marks above.
By declining coverage, I certify that I am enrolled in another group health coverage that is deemed to be minimal essential coverage
as required by law.
Participant Signature Date
If you are enrolling yourself in the medical plan, you must also sign under the “Authorization” section below.
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Authorization Required by Blue Shield:
I declare that the information given on this form is true and complete to the best of my knowledge and belief. I understand that the information
I have provided is the basis on which coverage may be issued under these plans. Any misstatements or omissions may result in future claims
being denied and/or my coverage(s) being rescinded. I know that if I do not enroll within 30 days of becoming first eligible (or within 31 days
of an IRS qualified change in status) I will have to wait until the next annual enrollment, and may be required to submit evidence of
insurability for certain coverage.
My signature below certifies that I have applied for the benefits indicated on this form. I understand that my benefit elections may result in
deductions from my pay and authorize my employer to make the required deduction.
Kaiser Foundation Health Plan, Inc., Arbitration Agreement* CALIFORNIA
I understand that (except for Small Claims Court cases, claims subject to a Medicare appeals procedure or the ERISA claims procedure
regulation, and any other claims that cannot be subject to binding arbitration under governing law) any dispute between myself, my heirs,
relatives, or other associated parties on the one hand and Kaiser Foundation Health Plan, Inc. (KFHP), any contracted health care providers,
administrators, or other associated parties on the other hand, for alleged violation of any duty arising out of or related to membership in
KFHP, including any claim for medical or hospital malpractice (a claim that medical services were unnecessary or unauthorized or were
improperly, negligently, or incompetently rendered), for premises liability, or relating to the coverage for, or delivery of, services or items,
irrespective of legal theory, must be decided by binding arbitration under California law and not by lawsuit or resort to court process, except
as applicable law provides for judicial review of arbitration proceedings. I agree to give up our right to a jury trial and accept the use of
binding arbitration. I understand that the full arbitration provision is contained in the Evidence of Coverage.
By enrolling in a Kaiser health plan, I understand that this action will serve as my electronic signature of agreement to the conditions provided
in the Kaiser Foundation Health Plan Arbitration Agreement (above) and that by law this electronic signature will have the same effect as a
signature on a paper form. Note: If you do not wish to accept the arbitration agreement above you must return to the plan selection section and
make a new Health Plan selection.
*Disputes arising from the following fully-insured Kaiser Permanente Insurance Company coverages are not subject to binding arbitration: 1)
the Preferred Provider Organization (PPO) and the Out-of-Network portion of the Point-of-Service (POS) plans; 2) Preferred Provider
Organization (PPO) plans; 3) Out-of-Area Indemnity (OOA) plans; and 4) KPIC Dental plans.
If any changes to this enrollment is deemed a mid-year qualifying event, you are responsible to inform your employer within 31 days of the
qualifying event date.
By signing below, I acknowledge all of the terms and provisions as described above.
I acknowledge that each dependent listed in the Enrollment Form meets the definition of dependent per the District’s health Plan rules and I
understand that any falsification, omission, or misrepresentation of information will be considered fraud and could lead to cancellation of the
plan and other necessary actions deemed appropriate by the District. I further acknowledge that I will be required to and, by my signature
below, hereby agree to reimburse the District for any insurance coverage expenses that the District incurred for ineligible dependent coverage,
including, but not limited to civil action. I further agree to notify the District within 31 calendar days if any of my eligible dependents become
ineligible (e.g., legal separation, divorce, death, or over-age dependent). I further agree to provide proof of eligibility upon request.
I further authorize the exchange of information necessary to provide the benefits afforded by the Plan.
Please sign and date this application:
Signature Date
Rev. 5/2023
Copy Sent to Providers: HR Input: Send Copy to Payroll __