Administrative Forms

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Administrative Forms

Please refer to the below Communication Guide to contact the appropriate vendor or provider of service when you have questions or need assistance. HealthSCOPE Benefits only submits enrollment to the other carriers and cannot respond to inquiries concerning those program benefits.  By contacting the appropriate vendor directly you will receive more timely assistance with your question.

COMMUNICATION GUIDE FOR MEMBERS


 

EMPLOYEES:  The New Employee Enrollee Form is to be used when you are enrolling in any of the medical, dental, vision or life programs for the first time, OR if you are currently enrolled and wish to drop coverage of any of the available products.  (Note:  Please be sure all forms are completed in their entirety, signed and dated. If enrolling dependents, their date of birth and SSN are required for enrollment.)

If you did not enroll in the life insurance when first eligible all amounts are subject to medical underwriting.  You will need to complete an Evidence of Insurability form that can be found under Voluntary Benefits / Life Insurance.

NEW EMPLOYEE ENROLLMENT FORM


 

EMPLOYEES:  The Change Enrollment form is to be used when you are currently enrolled in any of the medical, dental, vision or life programs and wish to make changes during the Open Enrollment period, at the time of a Special Enrollment Event, or a Qualifying Change in Status.  See the Plan Document for details on when you may enroll.   (Note:  Please be sure all forms are completed in their entirety, signed and dated.  If enrolling dependents, their date of birth and SSN are required for enrollment.)

CHANGE ENROLLMENT FORM