2024 Archdiocese of Atlanta / Lay Employee Quick Guide - Flipbook - Page 52
OTHER COVERAGE INFORMATION
This information you provide about other coverage will be used to coordinate benefits with any other group health plan you may have.
Please provide the month, day and year for effective dates of coverage.
1. Will your dependents continue to be covered under another health insurance or dental plan while covered by this plan?
Medical ެ Yes ެ No Dental ެ Yes ެ No
If yes, please answer the following:
a. Name of policy holder ___________________________________________ Date of birth ____________________________________________________
b. If this coverage is through your spouse's employer, please list the employer's name: __________________________________________________________
c. If this is not through an employer, please list the source of other coverage: _________________________________________________________________
Name of medical insurance company_____________________________________________ Telephone number __________________________________
Name of dental insurance company ______________________________________________ Telephone number __________________________________
ެ Children
d. Who will continue to be covered:
ެ Spouse
List names of covered persons:____________________________________________________________________________________________________
ެ Individual
ެ COBRA
ެ Other
e. Effective date of medical policy __________________ Type of plan:
ެ Group
f. Term date of medical policy ____________________
g. Effective date of dental policy ___________________ Type of plan:
ެ Group ެ Individual ެ COBRA ެ Other
h. Term date of dental policy ______________________
MEDICARE INFORMATION
1. Do your dependents currently have Medicare coverage? ެ Yes ެ No
(If yes, please answer the following:)
a. If you or your spouse are retired, please supply the retirement date(s) ____________________________________________________________________
b. Name of person covered by Medicare ______________________________ Medicare claim number ___________________________________________
c. Medicare eligibility is due to: ެ Overage 65 ެ End-stage renal disease ެ Total Disability
d. Part A effective date ____________________________________________ Part B effective date ______________________________________________
OTHER COVERAGE
1. Is there other coverage for your children due to a court decree? ެ Yes ެ No
If yes, name of parent(s) with legal custody of children: ________________________________________________________________
Address of parent(s) with legal custody: ____________________________________________________________________________
Is there a court order making the non-custodial parent responsible for the child(ren)’s medical/dental expenses?
If yes, please supply a copy of the legal documentation for this decision.
Failure to provide this information will result in denial of claims submitted for you or your family members.
ެ Yes ެ No
DECLINATION OF ENROLLMENT IMPORTANT! If you are waiving your dependents' right to coverage under this plan, you must
declare the reason for declination in writing below. Failure to declare your reasons for waiving coverage may limit your opportunity to
join the plan later.
If you are declining enrollment for your dependents (including your spouse) because of other health insurance coverage, you may in the future be able to enroll your
dependents in this plan, provided that you request enrollment within 31 days after your other coverage ends. In addition, if you have a new dependent as a result of
marriage, birth, adoption, or placement for adoption, you may be able to enroll your dependents, provided that you request enrollment within 31 days after the
marriage, birth, adoption or placement for adoption.
I have been given the opportunity to participate in the benefit plan, but after due consideration, I have elected not to participate in each of the categories checked
below:
Effective Date of Declination ___________________________________________________
SPOUSE
CHILD(REN)
List names of dependents to be declined: ______________________________________________________________________________________________
REASON FOR REFUSAL OF MEDICAL COVERAGE:
Have coverage under another plan. Name of Other Plan ______________________________________________________________________________
Indicate who is currently covered under other plan(s):
Spouse
Children
Other. Give Explanation _________________________________________________________________________________________________________
I understand that failure to specify that I am declining coverage because my spouse and/or children have other coverage may waive my special
enrollment rights as described above. I further understand that by not applying for the coverage above, I will not be entitled to those benefits.
I further understand that by applying for coverage at a future date, I may be asked to provide health status information. Penalties such as deferred
effective dates may be imposed. I hereby certify that I am declining coverage for the dependents indicated above because such dependents are
currently covered under the plan(s) named above, and that this information is true and correct to the best of my knowledge. I understand that if I
have provided false information regarding the coverage of my dependents under other plan(s) that I may be subject to adverse employment action,
including but not limited to termination.
X _______________________________________________________
;
Sign your name, DO NOT PRINT OR TYPE
Date
201503 10110208-0411 Page 2