|
Enrollment/Change
Form • Instructions
for Enrollment/Change Form
Employees and employers must complete this form for new enrollments
and adding or canceling dependents.
Notice
of Membership Adjustment Form
Employers may use this form as a cover sheet to summarize Enrollment/Change
Forms being submitted or use when notifying SchoolCare of coverage cancellation
for employee and/or dependents.
Domestic
Partner Affidavit Form
Each employer group has the option of electing domestic partner coverage
(same and opposite sex). Criteria for standard coverage is indicated
in the form, but the employer group has the right to adopt with more
stringent criteria.
Dependent Certification
Form
For dependents age 19 through 26 who are unmarried, a resident of NH
or enrolled as a student at a public or private institute of higher
education, and who are not covered under any other health plan or policy.
Disabled
Adult Verification Form
For dependents age 19 or older who are physically or mentally incapable
of self-support. Medical proof, including a physical examination by
the physician may be required.
Michelle’s
Law Verification Form
For dependents age 19 through 26 who are full-time students and take
a medically necessary leave of absence from school for a period not
to exceed 12 months. Documentation and certification of the medical
necessity of a leave of absence must be submitted to SchoolCare
by the student's attending physician and shall be considered prima facie
evidence of entitlement to coverage.
Identity
Theft Claim Kit
Provides members with information on how to report an ID Theft, who
to report this theft to and how to be reimbursed for fraudulent charges.
Identity
Fraud Expense Reimbursement Coverage • Identity
Theft Recovery Kit
Presents tips and steps to take in the future to safeguard against Identity
Fraud.
|
