The Wisconsin Health Application Form serves as a standardized document for small employers in the State of Wisconsin to initiate the enrollment process for group health insurance coverage. Crafted under the guidance of the Office of the Commissioner of Insurance, it adheres to the regulations stipulated in Section Ins 8.49, Wis. Admin. Code, and other relevant statutes. This comprehensive form aims to collect necessary information from employers and employees to ensure the effective administration of health benefits, while also providing options for waiving coverage under certain conditions.
In the bustling state of Wisconsin, the Small Employer Uniform Employee Application for Group Health Insurance emerges as a pivotal document facilitated by the Office of the Commissioner of Insurance, stationed in Madison. This comprehensive form not only marks the starting point for employers striving to secure health insurance coverage for their teams but also embodies the legislative underpinnings found in Sections 601.41 (8) and 635.10 of the Wisconsin Statutes, alongside Section Ins 8.49 of the Wisconsin Administrative Code. At its core, the form is designed for initial applications, urging employers and employees alike to engage with its various segments thoughtfully filled out to capture the essence of the coverage being sought. From laying down employer information to delving deep into employee specifics — inclusive of personal details, medical history, and coverage waivers — it meticulously gathers data pivotal for the insurance underwriting process. Furthermore, it touches upon Medicare details, prior and impending health coverage, and even extends to the selection of health providers or products, if applicable, ensuring a holistic approach towards health insurance enrollment. This form undeniably serves as a conduit to navigating the complexities of group health insurance within Wisconsin, symbolizing a step forward in fostering a healthier workforce.
Employee Name_______________________
SMALL EMPLOYER UNIFORM EMPLOYEE
State of Wisconsin
APPLICATION FOR GROUP HEALTH
Office of the Commissioner of Insurance
INSURANCE
P.O. Box 7873
Madison, WI 53707-7873
Ref: Section Ins 8.49, Wis. Adm. Code, and
(608) 266-3585
Sections 601.41 (8), 635.10, Wis. Stat.
Web Address: oci.wi.gov
This form is designed for an employer’s initial application for coverage. Please contact your agent or the insurer to determine if this form should be used in other situations once the group is enrolled with the insurer.
EMPLOYER INFORMATION – To be filled out by Employer
Employer Name _______________________________________
Group Number _______________
Division Number ____________
Employee Class __________________
Total number of permanent employees who have a normal work week of 30 or more hours _________
Names of Insurers to whom information may be released:
Insurer: _________________________________________________
I. EMPLOYEE INFORMATION
Employee Instructions: Please print using black or blue ink. Please fill out the entire application for each person for whom coverage is being sought.
Employee’s First Name, Middle Initial and Last Name: ________________________________________________________________________
Social Security No.: ____________________ Birth Date: ____________________ Sex: _________ Height and Weight:___________________
Street or Post Office Address: ___________________________________________________________________________________________
City: ___________________________________ County:_____________________ State: __________________ Zip: ________________
Home Phone: __________________ Work Phone: __________________ Email: _______________________________ [ ] Home [ ] Work
1.For your current employer: What was your first day of employment? ____/____/____
How many hours, on average, do you work each week? ______
2.Are You:
a)
[ ] Single
[ ] Married
[ ] Legally Separated
[ ] Divorced
[ ] Widow or Widower
If you are married, legally separated, divorced or widowed, please indicate the date that the event occurred: _____________________
If you are married, please indicate the county and state, or country in which you were married: _____________________
If you are married, please indicate your former or maiden name: _______________________________________________
b)
A Retiree?
[ ] Yes [ ] No
c)
On COBRA or State Continuation? [ ]Yes [ ] No
If “Yes,” provide start date and reason: ____________________________________________________________________________
II. TYPE OF HEALTH COVERAGE
Please select the type of health insurance coverage for which you are applying:
[ ] Employee Only
[ ] Employee and Spouse
[ ] Employee and Dependent Child(ren)
[ ] Employee, Spouse and Dependent Child(ren)
III. DEPENDENT INFORMATION
a)List all dependents, spouse and child(ren) applying for insurance. If you need additional space, please use a separate sheet of paper and attach it to this application (please sign and date the additional sheet).
Name
Social Security
Birth Date
Height
(First; M.I.; Last)
Sex
Number
Relationship
(Mo/Day/Yr)
Weight
Spouse
[ ] Child
[ ] Stepchild
[ ] Grandchild
[ ] Other
____________
Uniform Employee Application
Page 1 of 9
OCI 26-501 (R 6/2010)
b)Does the dependent child(ren) named within this application live with you at the address shown above? [ ] Yes [ ] No If “No,” please list the dependent child(ren)’s name and address(es):
________________________________________________________________________________________________________________
c)If there is a stipulation in a legal decree or court order stating who is responsible for providing health insurance of the named dependent child(ren), please indicate name of the person who has primary custody of the dependent child(ren) and the name of the responsible person for health insurance:
IV. MEDICAL INFORMATION
Please answer the following questions to the best of your knowledge. On the next page, please provide the complete details if you answer “Yes” to any of the questions below. The date that this application is signed is the date that you should use when answering questions that request you to provide prior history for various periods of time. The health insurance company does not use or collect genetic information for any underwriting purpose. Genetic information includes information related to genetic tests, genetic counseling, and any family history of a disease or disorder. Any such information should not be included on an application or communicated to the insurance company in any manner. Any genetic information that may be obtained will not be used for underwriting of health coverage. You are required to promptly notify your employer so that you may provide updated information to the small employer insurer(s) of any changes or developments in your, your spouse’s or your dependent child(ren)’s health history that occur prior to your employer’s notifying you that there has been an insurer’s underwriting decision regarding this application.
A.Are you, your spouse or any dependent child(ren) (even if not listed on the application) currently pregnant or an expectant parent? (If “Yes,”
due date is __________________)
B.Has anyone named in this application been treated or diagnosed by a medical professional as having Acquired Immune Deficiency Syndrome
(AIDS) or AIDS Related Complex (ARC)?
C. Has anyone named in this application used tobacco or smokeless tobacco during the past 12 months?
[ ] Yes
[
] No
If “Yes,” provide information as requested regarding the product, duration and frequency of use in section H below.
D. In the past 5 years has anyone named in this application been evaluated or treated for alcoholism or chemical dependency; or joined any
organization for alcoholism or chemical dependency; or used illegal drugs or been advised by a health care professional to reduce the use of
alcohol or illegal drugs?
E.Is anyone named in this application now disabled, mentally incompetent or unable to perform normal work or age-related activities? [ ]Yes [ ] No If “Yes,” please identify name(s), health condition(s), date(s) of disability and name(s) and address(es) of the attending physician(s):
F.Within the past 10 years, has anyone named in this application been counseled, consulted or treated for any of the following (please check all conditions that apply):
1. CIRCULATORY SYSTEM
3. GENITOURINARY SYSTEM
heart disease or disorder
menstrual disorder
stroke
genital disorder
circulatory disorder
sexual dysfunction
d)
chest pain
d) pregnancy complications (e.g., premature
birth, miscarriage, c-section)
e)
high or low blood pressure
infertility
f)
elevated cholesterol and/or triglyceride levels
urinary tract/kidney/bladder disorder
g)
anemia or blood disorder
prostate disorder
4. ENDOCRINE SYSTEM
2. DIGESTIVE SYSTEM
a) diabetes
ulcers
thyroid disorder
stomach disorder
adrenal disorder
liver/pancreas disorder
d) enlargement of the lymph-nodes
gallbladder disorder
e) connective tissue disorder
intestinal disorder (e.g., colitis, Crohn’s disease)
5. EAR OR EYE
hernia
eye disorder
rectal disorder
ear disorder
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6. RESPIRATORY SYSTEM
9. CANCER
allegry(ies)
cancer
asthma
tumor
emphysema
abnormal growth
sinus or nasal disorder
carcinoma in situ
lung disease or disorder
shortness of breath
10. BEHAVIORAL HEALTH
7. NERVOUS SYSTEM
attention deficit disorder
a) epilepsy or other seizures
psychological disorder
headaches
suicide attempt
multiple sclerosis
eating disorder
8. MUSCULAR or SKELETAL
arthritis
11. OTHER
fibromyalgia
a) organ or other type of transplant or implant
back disorder
breast disorder
joint disorder
lupus
musculoskeletal disorder
skin disorder
chronic fatigue syndrome
G.Within the last 5 years, has anyone named in this application to be covered by this insurance had any other injury, illness or treatment for any condition not already listed; been hospitalized or been scheduled for hospitalization; had surgery or had surgery scheduled; had a test or a test
scheduled; or been recommended to have a test or surgery which was not performed for any reason not already mentioned in this application?
We are not seeking the results of HIV Antibody test.
H.In the space below please list and provide the complete details if you answered “Yes” above to any of the questions or conditions contained in sections A through G. (Attach additional pages as needed and sign the additional pages.)
Question Number
Name of Person
Date(s) of Treatment
Give full details for each question answered “Yes,” state the condition, duration and degree of recovery.
Name and address of attending physician or other health care provider.
I.If anyone named in this application is taking medication or has had prescribed or recommended any medication during the period of time related to your answer (i.e. past 5 years, past 10 years, or currently taking), please list all those medications, dosages, and what medical condition is being treated or were treated by each medication in the space provided below. (Attach additional pages as needed and sign the additional pages.)
Name, dosage and frequency of medication
Name and address of prescribing
(include illness or health condition for which
Date(s) medication taken
physician or licensed health care
medication was prescribed)
(indicate if ongoing)
provider and dispensing pharmacy
V. WAIVER OF COVERAGE
I understand that I am eligible to apply for group health insurance through my employer. I do NOT want, and hereby waive, group health insurance for (check the box that applies):
] Waiving for myself
[ ] Waiving for my spouse
[ ] Waiving for my dependent child(ren)
] Waiving for me, my spouse and my dependent child(ren)
I am waiving group health insurance because (check all that apply):
[] I, the employee, am covered or will be covered under another plan that is not sponsored by my employer. I am not enrolled for coverage under the Health Insurance Risk-Sharing Plan (HIRSP). If currently covered, please attach a copy of your identification card for that plan.
[] I, the employee, do not have a risk characteristic or other attribute that would be the sole cause for the small employer insurer to make a decision with respect to premiums or eligibility for a policy that is adverse to the small employer.
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[] My spouse is covered or will be covered under another plan that is not sponsored by this employer. My spouse is not enrolled for coverage under the Health Insurance Risk-Sharing Plan (HIRSP). If currently covered, please attach a copy of your spouse’s identification card for that plan.
[ ] My dependent child(ren) is covered or will be covered under another plan that is not sponsored by my employer. My dependent child(ren) is not enrolled for coverage under the Health Insurance Risk Sharing Plan (HIRSP). If currently covered, please attach your identification card for that plan. Please list, below, the name(s) of the child(ren) for whom coverage is being waived.
[] I am not enrolled under the Health Insurance Risk-Sharing Plan (HIRSP) and the annualized premium contribution to be paid by me on behalf of myself or my dependent spouse and child(ren) would exceed 10% of my annualized gross earnings from this employer.
[] Other reason (Please provide a written reason for waiving coverage):
WAIVER: I certify that I have been given the opportunity to apply for group health insurance and decline to enroll as indicated above, on behalf of myself, my spouse and my dependent child(ren). I understand that by signing this waiver, I, my spouse, and my dependent child(ren) forfeit the right to coverage. I was not pressured, forced or unfairly induced by my employer, the agent or the insurer(s) into waiving or declining the group health insurance. If in the future I apply for coverage, I, my spouse, or any of my dependent child(ren) may be treated as a late enrollee and subject to postponement or an exclusion of coverage for preexisting conditions for a period of up to 18 months. This period may be offset by the time I, my spouse or my dependent child(ren) was covered under a qualified health plan.
I understand that if I am declining enrollment for myself, my spouse, or my dependent child(ren) because of other health insurance coverage, including Medicaid, I may in the future be able to enroll myself, my spouse, or my dependent child(ren) in this plan, provided that I request enrollment within 30 days after my other health coverage ends or 60 days after Medicaid ends. In addition, if I gain a dependent spouse or child(ren) as a result of marriage, birth, adoption, or placement for adoption, I understand that I may be able to enroll myself, my spouse and my dependent child(ren), provided that I request enrollment within 30 days after the marriage, birth, adoption or placement for adoption. If I am declining enrollment for myself, my spouse or my dependent child(ren) because of coverage under Medicaid, I understand that if I, my spouse or my dependent child(ren) become eligible for group health plan premium assistance under Medicaid, I may be able to enroll myself, my spouse or my dependent child(ren), provided I request enrollment within 60 days of initial eligibility for the premium assistance. I understand that I can obtain enrollment information from my employer or small employer group health insurance carrier.
Signature of Employee: _________________________________________________
Date Signed: _________________________
VI. MEDICARE INFORMATION
If you need to complete this section for more than one person, please use a separate sheet of paper and attach it to this application (please sign and date the additional sheet).
Are you, your spouse or your child(ren) covered by Medicare Part A? [ ] Yes [
] No Medicare Part B? [
] Yes [ ] No Medicare Part D [ ] Yes [ ] No
Name of person covered by Medicare: ____________________________________
If “Yes,” reason for Medicare: [ ] Over Age 65 [ ] Disability [ ] End-Stage Renal Disease (ESRD)
[ ] Disability and ESRD
Medicare Part A Effective Date: _________________
Medicare Part B Effective Date ___________________
Medicare Part C (Medicare Advantage) Effective Date: __________________
Medicare Part D Effective Date: ____________________
VII. CURRENT AND PREVIOUS COVERAGE
The information you provide about your other individual or group health insurance coverage (either prior or current) is necessary to determine whether you will have any waiting periods for preexisting conditions under the group health insurance plan under which you are applying for coverage. Your information will also help the small employer insurer(s) to coordinate benefits with any other group health coverage you may have. By providing this information you are not reducing your group health insurance for which you are applying.
Do you, your spouse or your dependent child(ren) listed in this application have current health insurance coverage or had previous health insurance coverage within the last 18 months? [ ] Yes [ ] No
If “Yes,” please complete the following table and attach a copy of the Certificates of Creditable Coverage for each person.
Starting with you, the employee, identify each person applying for insurance and include information for all current and previous health insurance coverage(s) in effect during the last 18 months.
Page 4 of 9
Effective
Termination
Type of
Date of
Coverage
Insurance Company, Plan &
Reason for Termination of
(see key
Group Number
(mo/day/yr)
below)
Type of Coverage Key: G = Group Comprehensive Major Medical; I = Individual Comprehensive Major Medical;
M = Medicare Supplement; D = Drug Coverage Only; H = Hospital Coverage Only; V = Vision Coverage Only
VIII. HEALTH PROVIDER OR PRODUCT SELECTION, IF APPLICABLE
This section should be completed only if the small employer group insurance for which you are applying requires the selection of a network, primary care provider or clinic. If applicable, it should also be used to select the product options offered by the employer or insurer. With respect to the provider or network selection, a selection should be made for each individual applying for such coverage and for each insurer from which insurance coverage is being sought. The provider numbers may be listed in the provider materials (i.e., directory) that are supplied by each insurer to your employer. The provider numbers for the same provider may not be the same for different insurers or products. Use additional sheets if necessary.
Insurer: ____________________________________________________________
Product Type: _______________________________________________________
Coinsurance Option: _______________
Deductible Option: _______________
Copayment Option: _______________
Selected Provider is for (choose only one): [
] Health Insurance [ ] Dental Insurance
[ ] Other ______________________________
Covered Person’s Name
Network or Provider’s Name or Number
Is this your current
provider?
IX. NON-HEALTH INSURANCE COVERAGE SELECTION, IF APPLICABLE
Availability of coverage is determined by your employer and whether the coverage is approved for issuance by the insurer(s). Please list the insurer(s) below from whom you are applying for coverage and check all benefits for which you are applying.
If you have been given a choice of plans to apply for, or if the coverage you are applying for requires the selection of a primary care provider/clinic/network, please complete the section entitled "Provider and/or Product Selection."
If you are waiving application for any coverage on yourself and/or your spouse and/or dependent child(ren), please complete the "Waiver of Coverage" section at the end of this section.
Page 5 of 9
A. GROUP DENTAL COVERAGE
[ ] Employee
Insurer: __________________________________________
Within the past 12 months, have you, your spouse or your dependent child(ren) had any individual or other group dental coverage? [ ] Yes [ ] No
If “Yes,” please provide the following information:
Orthodontia coverage? [ ] Yes [
Dental Insurer Name: ___________________________________________________
Policy Number: _______________________
Address: _____________________________________________________________
Phone Number: ______________________
Coverage Effective Date: __________________
Termination Date: __________________
Is coverage still in effect? [ ] Yes
[ ] No
Who was or is covered under the policy listed above? _________________________________________________________________
Please attach copies of Certificates of Prior Coverage.
B. GROUP LIFE/AD&D COVERAGE (dependent coverage only available if employee coverage elected)
Employee Life/AD&D Amounts:
Basic Issue $__________
Supplemental $__________
Optional $__________
Primary Beneficiary Name __________________________________
Beneficiary's Social Security ___________________
Relationship of Beneficiary ___________________
Secondary Beneficiary Name _______________________________
Dependent Life Amounts:
[ ] Dependent Spouse Only
[ ] Dependent Child(ren) Only
[ ] Dependent Spouse and Dependent Child(ren)
C. GROUP DISABILITY COVERAGE (only available to employees)
[ ] Short Term Disability
[ ] Long Term Disability
Your Annual Salary $__________________
Basic Benefit Amount $______________/ per week
Optional Benefit Amount $_____________/ per week
D. GROUP DRUG COVERAGE
E. GROUP VISION COVERAGE
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F.WAIVER OF NON-HEALTH COVERAGE - This section must be completed if you or your dependents do NOT want the coverage listed above that is available to you through your employer.
I understand that I am eligible to apply for coverage through my employer. I do NOT want coverage for (check all that apply):
Employee:
] Dental
] Basic Life/AD&D
[ ] Supplemental Life/AD&D
] Optional Life
] Basic Disability
[ ] Optional Disability [ ] Drug
[ ] Vision
Spouse:
] Basic Life
] Supplemental Life
] Drug
] Vision
Dependent Child(ren):
The reason I am waiving group coverage at this time is because of:
] Spousal coverage
[ ] Individual Coverage
[ ] Medicare
[ ] Medical Assistance
] Other:_______________________________________________________________________________________________________
WAIVER: I certify that I was not pressured, forced or unfairly induced by my employer, the agent, or the insurer(s) into waiving (declining) the above-noted coverage. I understand that in the event that I should decide to apply for such coverage at a later date, the application will be subject to the applicable terms and conditions of the employer’s policy(s), which may require additional limitations and waiting periods. I also understand that I, my spouse and my dependent child(ren) may be required to furnish, at my own expense, evidence of health status/health history representation satisfactory to the insurer(s). I understand that the insurer(s) reserves the right to deny coverage with any future application for coverage.
Signature of Employee: _______________________________________________
Date Signed: __________________
Signature of Spouse: _________________________________________________
X. TERMS AND CONDITIONS
I hereby enroll for coverage under the insurance coverage(s) for which I am presently eligible, or for which I may become eligible under my employer’s group contract(s). I have indicated in this Wisconsin Uniform Employee Application for Small Employer Group Health Insurance, if required, the Provider or Product Selection. I understand and agree that the information obtained by using this Application will be used by the insurer(s) to determine eligibility for benefits under my employer’s group insurance policies. I, on behalf of myself, my spouse and my dependent child(ren), if any, named herein, agree to cooperate in providing the insurer(s) with information needed to process this Application. This might include signing a form for the release by hospitals, doctors, and other health care providers of pertinent heath care records to the Medical Information Bureau, the insurer(s) or their legal representatives.
I acknowledge that I have read and completed the entire Application. If I received assistance in reading or completing this Application, I have identified in the space provided below the person(s) who provided me with such assistance. I declare and agree that the answers are, to the best of my knowledge and belief, complete and true and, together with any supplements or addendums thereto, shall be the basis for any certificate of coverage or certificate of insurance issued. I understand and agree that neither the employer nor the agent has the authority to waive a complete answer to any question, pass on insurability, alter any contract, or waive any of the insurer’s other rights or requirements. I additionally agree that the insurer(s) is not liable for any statement, representation, or other information provided to me, my spouse or my dependent child(ren) that is not expressly contained in a written document provided by the insurer and signed by an authorized officer of the insurer. I agree that no insurance will be effective until the date specified by the company on the certificate of coverage or certificate of insurance after this application has been accepted. I understand that any misrepresentation contained herein and relied upon by the insurer may be used to reduce or deny a claim or void the contract within the contestable period if such misrepresentation materially affects the acceptance of risk. I also understand that if I decline any coverage, future changes in coverage are NOT automatic and may be subject to the insurer’s approval.
I understand and acknowledge that any person who, with intent to defraud or knowledge that the person is facilitating a fraud against an insurer, submits an application or files a claim containing a false deceptive statement is committing a fraudulent act that is a crime. I further understand and acknowledge that in some states, any person who, for the purpose of intentionally misleading an insurer or other person, conceals significant information from an application or claim is committing a fraudulent act.
If any payroll deductions are required for this coverage, I authorize such deductions from my earnings. I reserve the right to revoke this deduction authorization at any time upon written notice to the employer. An Application should not be submitted more than 45 days prior to the effective date. This document will become a part of the insurance contract when coverage is approved and issued.
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I understand that I may request a copy of this Application and the Authorization to Use and Disclose Protected Health Information that are part of this Application. I agree that a photographic copy shall be as valid as the original. A legible facsimile signature shall have the same force and effectiveness as the original.
Signature of Spouse: ___________________________________________________
Signature of each listed dependent who has attained the age of 18:
________________________________________
Date Signed: ___________
Print Name ___________________________
Complete this section if someone assisted you in the completion of this Application.
The following person assisted me in completing the Application: _______________________________________________________
Please explain your relationship with the Applicant: _________________________________________________________________
AUTHORIZATION TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION
Instructions: Please read this authorization form carefully before signing. This form must be signed by each adult person seeking coverage, including all adult dependent children. Parents should sign for their minor children unless the minor has received treatment without parental consent, consistent with state law. Your application cannot be processed without a signature for each person seeking coverage. Signing this form is a condition of coverage: if you decide not to sign, you will not be enrolled in a health plan of the insurers listed below. You have the right to receive a copy of this form following your signature.
I. Protected Health Information
By signing this form, I authorize certain organizations and persons to use or disclose my, my spouse’s and my dependent child(ren)’s protected health information. Protected health information includes, but is not limited to, hospital records, physician records, lab results, mental health records, and alcohol and/or drug abuse records. Protected health information may be written, oral, or electronic. This form does not permit the use or disclosure of psychotherapy notes or the disclosure of information concerning whether I, my spouse or my dependent child(ren) have obtained a test for the presence of HIV antigen or nonantigenic products of HIV or an antibody to HIV or what the results of this test were.
II. Purpose of this Authorization Form
By signing this form, I, my spouse and my dependent child(ren) authorize the use and disclosure of protected health information for the purposes of pre-enrollment underwriting or risk-rating of health insurance coverage for me, my spouse and my dependent child(ren), to determine eligibility for enrollment or benefits under a health plan or to allow the insurer to conduct utilization review and quality improvement activities (“Purpose”).
III. Entities Authorized to Use and Disclose My Protected Health Information
Insurers: I hereby authorize the following insurers, their reinsurers, and their legal representatives (“Insurers”) to receive, use, and disclose my, my spouse’s and my dependent child(ren)’s protected health information for the Purpose listed above:
I authorize the Insurers to disclose my, my spouse’s and my dependent child(ren)’s protected health information: between themselves, to reinsuring companies, and to the plan administrator (if other than the employer), plan sponsor (if other than the employer), insurance intermediaries, or other persons or organizations performing business or legal services in connection with the Purpose above.
I further authorize any licensed physician, medical practitioner, health care provider, hospital, clinic, or other medical or medically related facility, insurance or reinsuring company, Medical Information Bureau, Inc., consumer reporting agency, or other organization, institution, or person that has any record or knowledge of me, my spouse or my dependent(s), to give to Insurers any and all protected health information about me, my spouse, or my dependent(s) to be covered concerning diagnosis, treatment and prognosis for any physical or mental condition, history or character, general reputation, personal trait, and mode of living, including, but not limited to, all medical and health care records, but not including whether I, my spouse or my dependent(s) obtained a test for the presence of HIV antigen or nonantigenic products of HIV or what the results of this test were.
I, my spouse and my dependent child(ren) understand that protected health information described in this form may be used by, or disclosed to or by, organizations and persons who are not subject to federal or state privacy laws.
IV. Term of Authorization
I agree this Authorization shall be valid for two and one half (2 ½) years from the latest signature date below.
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V. Right to Revoke
I understand I, my spouse or my dependent child(ren) may revoke this authorization at any time by giving advance written notice to Insurers. Revocation of this authorization form will not affect actions Insurers and others took in reliance on this form prior to the written notice of revocation.
I HAVE HAD FULL OPPORTUNITY TO READ AND CONSIDER THIS FORM. I UNDERSTAND THAT, BY SIGNING THIS FORM, I AUTHORIZE THE USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION DESCRIBED IN THIS FORM. I UNDERSTAND THAT I MAY ONLY REVOKE AUTHORIZATION FOR MYSELF OR MY MINOR CHILD(REN) UNLESS MY MINOR CHILD(REN) HAS RECEIVED TREATMENT WITHOUT MY CONSENT, CONSISTENT WITH STATE LAW. (CONTINUED ON THE NEXT PAGE.)
_______________________________________
_____________________
_________________________________
Signature of Adult Applicant
Date signed
Printed Name
Signature of Spouse (if applicable)
AUTHORIZATION TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION (Continued)
I HAVE HAD FULL OPPORTUNITY TO READ AND CONSIDER THIS FORM. I UNDERSTAND THAT, BY SIGNING THIS FORM, I AUTHORIZE THE USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION DESCRIBED IN THIS FORM. I UNDERSTAND THAT I MAY ONLY REVOKE AUTHORIZATION FOR MYSELF OR MY MINOR CHILD(REN) UNLESS MY MINOR CHILD(REN) HAS RECEIVED TREATMENT WITHOUT MY CONSENT, CONSISTENT WITH STATE LAW.
Signature of Adult Dependent
(if applicable)
Signature of Parent or Legal Guardian
Name of Minor Child (please print)
for Minor Child(ren) (if applicable)
If signing for more than one child, please list the names of each child for whom you are signing:
_________________________________________
For services received by a minor that under state law the minor may consent to treatment without parental or legal guardian consent:
for Minor Child (if minor received
treatment with knowledge of parent)
Signature of Minor Child (if minor may have
received treatment that does not require
parent or legal guardian authorization)
Page 9 of 9
Filling out the Wisconsin Uniform Employee Application for Group Health Insurance might seem challenging, but taking it step by step can simplify the process. This form is generally used by small employers in Wisconsin to enroll their employees in group health insurance plans. It's critical for employees to provide accurate and complete information to avoid issues with coverage eligibility or delays. After completing the application, the next steps typically involve submission to the employer or insurance agent, who will then process the application with the chosen insurance company. Let's dive into the steps to fill out this form.
After submitting your completed Wisconsin Uniform Employee Application for Group Health Insurance, your employer or insurance agent will review it for completeness and submit it to the insurance company. The insurance company will then process your application and notify you or your employer of the application status. Remember to keep a copy of your completed form for your records.
What is the purpose of the Small Employer Uniform Employee Application for Group Health Insurance in Wisconsin?
The Small Employer Uniform Employee Application for Group Health Insurance is a form designed for employers in Wisconsin to use when they're applying for initial health insurance coverage for their employees. It's a pathway for businesses to secure health insurance for their staff through the State of Wisconsin's Office of the Commissioner of Insurance. The application assists in gathering vital employee information to ensure appropriate coverage options can be extended.
Who needs to fill out the Wisconsin Health Application form?
This form should be completed by the employer for the initial group health insurance coverage application. Information regarding the business, such as employer name and group number, will be filled out by the employer. Additionally, detailed personal, medical, and coverage waiver information must be provided by each employee requesting to be covered under the group health insurance plan. It's a collaborative process to compile the necessary details for insurance underwriting.
What information do employees need to provide on the application form?
Employees are required to provide comprehensive details that include their personal information (name, social security number, contact details), employment specifics, dependent information, and medical history. Furthermore, they must indicate their desired type of health insurance coverage, any current or prior health insurance coverage, including Medicare information if applicable, and complete sections on medical information that cover a wide range of health questions and conditions.
Are there specific sections an employee must complete regarding their health history?
Yes, employees must answer questions related to their health history meticulously. This includes, but is not limited to, current pregnancy status, past or present treatments for specific diseases, tobacco or smokeless tobacco use, evaluations or treatments for alcoholism or chemical dependency, and any disabilities. Full disclosure is necessary to ensure accurate underwriting and the availability of appropriate health coverage options.
What happens if an employee decides to waive the group health insurance coverage?
Employees have the option to waive group health insurance coverage offered by their employer through this form. They must indicate the reason for waiving, such as having coverage under another plan not sponsored by the employer or other personal reasons. It is important to note that waiving coverage might affect eligibility for future enrollment, particularly concerning preexisting conditions and the timing of such enrollments.
How does Medicare information impact the application process?
If an employee, their spouse, or dependent child(ren) is covered by Medicare, details regarding their Medicare Part A, B, C, or D coverage must be provided. This information is vital for assessing potential coordination of benefits and ensuring that the health coverage applied for complements the Medicare benefits already in place, without any overlap or gaps in coverage.
What is the significance of providing current and previous health coverage information?
Providing details about current and previous health insurance coverage helps the insurer determine if any waiting period for preexisting conditions applies to the applicant. It also aids in the coordination of benefits if the employee, their spouse, or dependents have other health insurance coverage. Accurate and complete insurance history information ensures that employees receive the full benefit of their coverage without undue delay or denial of valid claims.
Filling out the Wisconsin Health Application form is a crucial step for employees seeking health insurance coverage through their small employers. However, mistakes in the application process can lead to delays, inaccuracies in coverage, or even a denial. Understanding these common pitfalls can help applicants avoid unnecessary complications.
Incorrect or Incomplete Personal Information: One basic yet frequent mistake is the provision of incorrect or incomplete personal information. This includes misspelling the employee's name, providing an outdated address, or inaccurately entering the social security number or birth date. Such errors can significantly delay the processing of an application or lead to issues with insurance claims in the future.
Failure to Disclose Health History Accurately: The sections concerning medical history and current health status require careful attention. Applicants sometimes fail to disclose their full health history due to privacy concerns or simply overlooking the details. Not only does this jeopardize the accuracy of the application, but it could also affect the coverage one receives. Insurance companies need complete health information to determine the right coverage plan.
Not Listing All Dependents: Applicants often forget to list all eligible dependents, such as new-borns or step-children, who are intended to be covered under the plan. This oversight can lead to certain family members not being covered when they need health services. It’s important to review the dependent section thoroughly to ensure that all family members requiring coverage are listed.
Omitting Previous Health Insurance Information: The application form requests information regarding any current or past health insurance coverage within the last 18 months. A common mistake is omitting this information or not providing enough details. Previous health insurance data is crucial for determining preexisting condition waiting periods and for coordinating benefits if multiple coverage exists.
Ensuring the accuracy and completeness of the Wisconsin Health Application form is critical. Each section of the form serves a specific purpose in the insurance enrollment process, from personal identification to medical history, and any inaccuracies can create barriers to obtaining the desired health coverage. Taking the time to double-check entries and confirm all required information can lead to a smoother enrollment process.
In the process of completing the Wisconsin Health Application form, applicants may find it beneficial to include additional documentation to support their application or to meet specific requirements set forth by the health plan or the employer's guidelines. Below is a brief overview of four forms and documents frequently used alongside the Wisconsin Health Application form:
Collecting and submitting these documents, as applicable, can be crucial for the timely and accurate processing of a health insurance application. Prospective enrollees should ensure they understand what additional information may be necessary and how to properly secure and submit these documents to support their health insurance application.
The Wisconsin Health Application form closely resembles an Employee Benefits Enrollment Form often used by companies to enroll employees in various types of benefits, including health, dental, and vision insurance. Like the Wisconsin form, these enrollment forms collect personal and dependent information, outline the types of coverage available, and require the employee to select their desired level of coverage. Both forms serve as an initial point of entry into an insurance program, facilitating the gathering of essential information needed by the insurer to provide coverage.
Similarly, the form mirrors the structure of a Life Insurance Application. These applications collect detailed personal and health history information to assess the applicant's risk and determine their eligibility for insurance. Life insurance applications also typically include sections for beneficiary designation, which, while not directly featured in the Wisconsin form, falls under the umbrella of providing personal information for the benefit of others, analogous to providing dependent information for health coverage purposes.
The form also has elements in common with Medicare Enrollment Forms, which are used for individuals looking to receive Medicare benefits. This similarity is particularly apparent in the sections of the form that inquire about current and previous health coverage, as these are crucial for determining enrollment periods and the coordination of benefits with Medicare. Furthermore, questions about Medicare status on the Wisconsin form underline the necessity of understanding an applicant's existing coverages, a commonality shared with Medicare enrollment.
A Disability Insurance Claim Form is another document that shares similarities with the Wisconsin Health Application form, especially in its comprehensive collection of medical information. Both types of forms require detailed health histories and the disclosure of any conditions that may affect the applicant's eligibility or the extent of coverage. This involves a detailed review of the applicant's physical well-being and any treatments, medications, or diagnoses that may influence the insurance outcomes.
Notably, the form shares similarities with the Patient Health History Form typically used by healthcare providers to gather a new patient's medical history. Both documents require detailed past medical information, including surgeries, hospital stays, and current health status. This similarity underscores the importance of understanding an applicant's health background to provide appropriate health insurance coverage or medical care.
A COBRA Election Notice also presents parallels with the Wisconsin Health Application form, especially in regards to sections of the form that discuss previous and current coverage, including COBRA. Both types of documents are integral in the transition between different health coverage plans, ensuring that individuals understand their rights and options regarding health insurance during periods of unemployment or after leaving a job.
Lastly, the Similarity can be drawn with a Health Risk Assessment (HRA) form that many insurers and employers use to evaluate an individual’s health risks and habits. Both the Wisconsin form and HRAs ask questions about health history, tobacco use, and pregnancies, aiming to identify potential health risks. This information helps in tailoring health plans or wellness programs to the individual's needs, emphasizing preventative care and healthy lifestyles.
When you're filling out the Wisconsin Health Application form for group health insurance, there are several things you should keep in mind to ensure the process goes smoothly and you provide accurate information. Here is a list of do's and don'ts:
Remember, accurately and thoroughly completing the Wisconsin Health Application form is crucial for securing group health insurance coverage. Take your time, review your answers, and ensure all information is correct before submission. If you have questions or doubts about any part of the form, don't hesitate to ask your employer or insurance agent for clarification.
When dealing with the Wisconsin Health Application form, there are several common misconceptions that need clarification:
Understanding these misconceptions helps streamline the process of completing the Wisconsin Health Application form, ensuring employees and their dependents can access the health coverage they need.
Filling out the Wisconsin Health Application form is an essential step for employees seeking group health insurance through their small employer. Here are key takeaways to consider while completing and using this form:
Thoroughly completing the Wisconsin Health Application form ensures accurate and efficient processing of group health insurance coverage. Employees should consult with their employer or insurance agent for any clarifications or assistance needed during this process.
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