Section I. Reason for application (for employer, reason selection must be completed in its entirety)
EnrollmentChange/CorrectionCancel Coverage

Section II. Employee and Family Demographics (Elections)

Instructions: Complete all applicable fields. If spouse or dependents are waving medical, dental, or vision coverage, see section IV. If section I.A was completed, you must complete this section.
Optional fields are indicated by italics.

Add Spouse Information

Dependent Information

How many dependents would you like to list?
012345

Section III. Other Health Insurance

Name of Covered Member:

Name of Health Insurance Company:

Policy Number:

Effective Date:

Section IV. Tobacco Use
Tobacco use means that a person currently uses or has used tobacco an average of four or more times a week within the past six months. Tobacco includes all tobacco products. However, religious or ceremonial uses of tobacco (for example, by Native Americans and Alaska Natives) are specifically exempt. Do you or any dependents over the age of 21 use tobacco? If yes, please provide the following information:

How many tobacco users would you like to list?
0123456

Section V. Waiving Coverage

In compliance with requirements under the Affordable Care Act, pediatric dental and vision services will be covered for individuals under age 19 who are members of group plans with 50 or fewer employees. However, dependents under age 19 who are enrolled in a UPMC Health Plan medical plan may still enroll in a standard commercial dental plan, a premium commercial dental plan, or in another carrier’s employer-sponsored dental or vision plan. In cases of dual coverage, the essential health benefits (EHB) pediatric dental coverage will act as the primary coverage for the EHB-eligible dependents, and the standard or premium commercial dental plan will act as secondary coverage.
The subscriber should make one selection for medical, dental, and vision coverage. If the subscriber waives medical, dental, or vision coverage, such coverage will not be available for his or her dependent(s). The dependent(s) must be enrolled in the same plan as the subscriber, unless the dependent(s) waives coverage. If the dependent(s) waives coverage, a reason must be marked.
Please sign here only if you are declining coverage for yourself, your spouse/domestic partner, and/or your dependent(s).
I acknowledge that I have been given the right to apply for this coverage; however, I, and/or my spouse or dependent(s), am/are electing not to enroll. I acknowledge that I, and/or my spouse/domestic partner or dependent(s), may have to wait until the plan’s anniversary date to be enrolled in group coverage.

Section VI. Disclosure of Protected Health Information

By accepting coverage and upon signing this application, for so long as I am enrolled in UPMC Health Plan, I understand, on behalf of myself and my eligible dependents and spouse, if any, that all of my/our health care, dental, and/or vision providers may release to UPMC Health Plan or its authorized agents all information related to my/our medical, dental, and vision history and treatment, including mental health, substance abuse treatment/conditions, and AIDS-related information, if any, for all lawful purposes relating to the administration of my health/dental/vision benefits, including determining or reviewing coverage claims, quality assurance, clinical resource management, and utilization review for services that I/we request or receive. I further understand that UPMC Health Plan may release such information to health care, dental, and/or vision entities for such purposes. I understand that I have the right to revoke this consent in writing at any time, and acknowledge that my right to revoke will not apply to the extent that UPMC Health Plan or any other provider has already acted in reliance on this statement. The term “UPMC Health Plan” collectively refers to UPMC Health Plan Inc., UPMC Health Coverage Inc., UPMC Health Options Inc., and UPMC Health Benefits Inc.
I further understand that information may be released by, to, or among the various UPMC Insurance Services Division entities for all lawful purposes, including administration of workers’ compensation and short-term disability, medical management, and implementation of health/wellness initiatives.
I have read and agree with the terms as stated on this Employee Benefit Election and Change form. Subject to revocation by me by written notice to my employer, I authorize the required deduction (if any) of applicable contributions from my wages.
I agree that all information on this Employee Benefit Election and Change form is true and correct to the best of my knowledge and belief. I understand that this form is the basis upon which coverage may be issued under the plan.
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. I UNDERSTAND THAT PROVIDING FALSE INFORMATION OR OMITTING RELEVANT INFORMATION IN THIS APPLICATION MAY RESULT IN THE DENIAL OF CLAIM(S) OR CANCELLATION OF COVERAGE.
UPMC Health Plan administers benefit plans underwritten by UPMC Health Plan Inc., UPMC Health Benefits Inc., UPMC Health Coverage Inc., and UPMC Health Options Inc. This managed care plan may not cover all your health care expenses. Read your contract carefully to determine which health care services are covered.

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