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 Important Coverage Notice - SurgiCenter/Sutter Health Group
| ENROLLMENT
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Universal Enrollment Form
Universal Enrollment Form
Dependent Coverage Provision
If you have a change of family status, or need to add/delete a dependent, you must complete this form and return to HR within thirty-one (31) days from the life qualifying event.
Copies of:
- birth certificate(s) (for ALL dependents),
- marriage certificate or Domestic Partner Affidavit, (if applicable) and
- social security card(s) (for ALL dependents)
must be included with the form.
For all deletions, see COBRA and HIPAA information below. Through COBRA, your former dependent may be eligible to continue his/her benefits coverage. To delete an ex-spouse, you must provide a divorce decree.
**If you fail to notify the District and submit the appropriate paperwork within 31 days, then you may add the dependent later during the annual open enrollment.
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| KAISER
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FORMS AND BILLING
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| EPO MEDICAL PLAN (formerly known as PPO NETWORK ONLY)
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UnitedHealthcare
- EPO MUST choose providers contracted with the UnitedHealthCare Choice Health Plan.
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FORMS AND BILLING
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DISEASE MANAGEMENT PROGRAM FOR PPO NETWORK ONLY AND PPO+ PLAN - Effective July 1, 2006
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HOW TO REPLACE OR REQUEST ADDITIONAL ID CARDS (employees or dependents):
First, access the web page: www.MyUHC.com. Under the section on the right, "Need a username and password?", you must register on-line by entering the newly assigned ID number (listed on your ID card), or your SSN to register. Then, set your own LOGIN and PASSWORD to access personalized health care, benefits information and order ID cards.
Once logged in, go to the "Manage my Account" menu at the top, and then choose, "Request ID cards".
Please Note: Individuals can only place one ID card request per individual per day. If you need to request more cards for the same person, please try again tomorrow. Otherwise, you can print a temporary ID card immediately.
If you are experiencing technical difficulties, while accessing myuhc.com, please contact UHC Technical Support at (877) 844-4999.
If you don't have access to a computer, you can always contact UHC customer care at 1-800-510-4846.
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| PPO MEDICAL PLAN (formerly known as PPO+)
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UnitedHealthcare
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FORMS AND BILLING
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DISEASE MANAGEMENT PROGRAM FOR PPO NETWORK ONLY AND PPO+ PLAN - Effective July 1, 2006
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HOW TO REPLACE OR REQUEST ADDITIONAL ID CARDS (employees or dependents):
First, access the web page: www.MyUHC.com. Under the section on the right, "Need a username and password?", you must register on-line by entering the newly assigned ID number (listed on your ID card), or your SSN to register. Then, set your own LOGIN and PASSWORD to access personalized health care, benefits information and order ID cards.
Once logged in, go to the "Manage my Account" menu at the top, and then choose, "Request ID cards".
Please Note: Individuals can only place one ID card request per individual per day. If you need to request more cards for the same person, please try again tomorrow. Otherwise, you can print a temporary ID card immediately.
If you are experiencing technical difficulties, while accessing myuhc.com, please contact UHC Technical Support at (877) 844-4999.
If you don't have access to a computer, you can always contact UHC customer care at 1-800-510-4846.
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| MAIL ORDER PRESCRIPTIONS
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Medco
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FORMS AND BILLING
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| COBRA
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COBRA and HIPAA rights
Click here for the current COBRA rates and HIPAA regulations.
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| UNIFORMED SERVICES EMPLOYMENT AND REEMPLOYMENT RIGHTS ACT
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USERRA
USERRA Notice
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| WOMEN'S CANCER RIGHTS ACT of 1998
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WCRA
WCRA Notice
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| CREDITABLE COVERAGE
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MEDICARE PART D and Prescription Drugs Program
CREDITABLE COVERAGE DISCLOSURE NOTICE
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