2022 Archdiocese of Atlanta / Lay Employee Quick Guide - Flipbook - Page 50
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
Name of dental insurance company
d. Who will continue to be covered:
List names of covered persons:
e. Effective date of medical policy
Type of plan:
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
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
c. Medicare eligibility is due to: ❑ Overage 65 ❑ End-stage renal disease
d. Part A effective date
Medicare claim Number
❑ Total Disability
Part B effective date
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? ❑ Yes ❑ No
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.
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
Effective Date of Declination ___________________________________________________
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):
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.
Sign your name, DO NOT PRINT OR TYPE