These printable forms are in PDF format. To read and print them, you need the free
Adobe Acrobat Reader (which may already be installed on your system). If you do
need to install it, click below.
Complete and Print Forms
You can complete all of the forms listed below on your computer before you print.
Simply click on the form and type in the appropriate information. Then print the
completed form, sign and mail to the address indicated on the form.
Enrollment
Member Enrollment Form
This form is used to add new members to an HMO or POS group policy.
Member Change Form
This form is used to make changes to an existing member’s coverage, to add or remove
dependents, to change demographic information and to cancel coverage.
Adult Child Dependent Enrollment – FOR EMPLOYER USE ONLY
Health Tradition is required to offer coverage for eligible adult children, but employees are not
required to cover their eligible adult child unless they choose to. Health Tradition is providing a
special enrollment period during the month of December through January 31, 2010, for employees to
enroll an eligible adult child. The effective date of coverage for an adult child who is enrolled
during the special enrollment period is January 1, 2010. If, however, employees do not elect coverage
during the special enrollment period and later wish to add their eligible adult child to the policy,
coverage may be subject to a waiting period for pre-existing conditions unless there is a qualifying event.
Employees must complete the attached Adult Child Eligibility Verification Form
and return it to his/her employer. After the employee has completed this form and determines he/she will
enroll the adult child in the health insurance policy, the employee will also need to complete a Member Change Form
,
to add or remove dependents from their health insurance policy. Please keep the Adult Child Eligibility Verification Form
for your records and return the Member Change Form
to Health Tradition Health Plan.
COBRA (For Employers) Forms
COBRA forms are currently available under the Federal COBRA site at
www.dol.gov/dol/topic/health-plans/cobra.htm.
The American Recovery and Reinvestment Act of 2009
The economic stimulus package signed into law by President Obama includes important new COBRA compliance obligations. The new law, known as the American Recovery and Reinvestment Act of 2009 (Act), creates detailed new rights to COBRA premium assistance for employees (and their families) who are involuntarily terminated between September 1, 2008 and December 31, 2009. It also adds an option to change enrollment to a different plan. Employers, insurers and administrators will need to implement the COBRA provisions in this legislation on very short notice. The Act is effective on the date of enactment (February 17, 2009) and provides premium assistance, for most plans, as of March 1, 2009. For an overview of the Act, please click on the link below.
American Recovery and Reinvestment Act of 2009 overview.