Attachment 15 - Health Insurance Enrollment Questionnaire


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Attachment 15 - Health Insurance Enrollment Questionnaire (pdf)


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AmeriCorps
National

AmeriCorps*VISTA

AmeriCorps*NCCC

National Service Fellows

NEW ENROLLMENT QUESTIONNAIRE

In order to accurately process your claims, information regarding other health care coverage is needed. Please complete the information below, sign at the bottom of the form and return the form to the address above.

YOUR NAME:

SOCIAL SECURITY NUMBER:

YOUR ADDRESS: (Street, City, State, Zip Code)

SECTION I: GENERAL INFORMATION

Do you have any other insurance coverage for health, dental, vision or Medicare?

  • YES (If YES, please complete all sections below.)
  • NO (If NO, please sign form and return.)
NAME(S) OF POLICYHOLDER
RELATIONSHIP TO YOU TYPE OF COVERAGE
( ) Policyholder Health
(  ) Group / (  ) Individual
( ) Spouse Dental
(  ) Group / (  ) Individual
( ) Parent Vision
( ) Group Individual
( ) Other Medicare

SECTION II: INFORMATION RELATED TO OTHER INSURANCE COVERAGE

Policyholder Name

Policyholder Social Security Number

Policy Number

Employer / Sponsoring Organization Name

Employer / Sponsoring Organization Telephone

Policy Effective Date

Employer Street Address

  • City State Zip Code

Name of Insurance Company

Location of Insurance Company (city/state)

Insurance Company Telephone

SECTION III: POLICYHOLDER SIGNATURE

I permit any physician, pharmacist, hospital or other health care provider, any insurer, prepayment organization or other health plan provider to give the Corporation for National Service any medical information about me, including information about physical and mental health, medical history, any drug or alcohol benefits.

This authorization shall remain in effect until all matters relating to these claims are concluded. A copy of this authorization will be as valid as the original. I understand that I may receive a copy of this authorization if I ask for one in writing.

Policyholder Signature

Policyholder Telephone

Date


Privacy Act Statement: This information is provided pursuant to Public Law 93-579 (Privacy Act of 1974) for AmeriCorps members completing Federal records and forms that solicit personal information. This authorization will be used to obtain information about an AmeriCorps member's medical history so that any medical claim filed by an AmeriCorps member can be processed expeditiously. No other uses will be made of this information. Effects of Non-Disclosure: Providing this information is voluntary; however, failure to authorize the release of any medical information may delay the processing of the medical claim.

Return to: Outsourced Administrative Systems, Inc. P.O. Box 33757 Indianapolis, IN 46203-0757 800.847.8217 f. 317.614.2136

VISTA-007 (01/00)