Benefit Plan Enrollment Form
Temp Employees - New Hires
Health Access Solutions, Health Access Benefit
* Unlimited virtual access to a personal primary physician including mental health, pediatric and OB/GYN services for you and your children* Reimbursement for screenings and preventive services, including annual wellness exams and physician-recommended wellness laboratory services, with an easy claim submittal process* Unlimited access to very low-cost prescriptions* Affordable premiumBowTie Virtual Direct Primary Care – Included with your Health Access coverage * Dedicated personal doctor that you interact with each time you have a “virtual visit”* Unlimited scheduled video and phone visits Monday to Friday, 9am to 6pm, scheduled via mobile app or website* Your dedicated doctor can prescribe medication, refer you to a specialist, and order labs and imaging if needed* Over 1,500 health issues supportedDiscount Prescriptions – Included with your Health Access coverage* Find the best price at over 65,000 pharmacies nationwide – major national chains and local pharmacies* Access to Manufacturer Savings and Patient Assistance Programs* Access to international pharmaciesPreventive Care – Included with your Health Access coverage* Preventive physician visits and services at no cost after reimbursement
Delta Dental PPO
I hereby request coverage for me and all dependents as indicated on this form and authorize my employer to make necessary deductions from my earnings unless indicated otherwise. I understand that if I do not enroll when first eligible, I will not be able to obtain coverage in the future except at annual enrollment or within 30 days of a family status change as listed below:
1. Marriage; 2. Divorce or legal separation; 3. Death of a spouse or dependent; 4. Birth or adoption of a child; 5. Termination or commencement of spouse’s employment; 6. A change in employment status of the employee or his/her spouse from part-time to full-time or full-time to part-time; 7. The taking of an unpaid leave of absence by the employee or his/her spouse; 8. A significant change in the health coverage of the employee or his/her spouse’s employment.
I certify that all the information furnished by me is true and correct. I understand that if I have provided any false, incomplete or misleading information, then my coverage under this plan may result in a denial of all benefits. I understand that all benefits are subject to the terms and conditions stated in the certificates.
Notice: a person may be committing insurance fraud if he or she submits an application or claim containing a false or deceptive statement with intent to defraud (or knowing that he or she is helping to defraud) an insurance company.
I hereby authorize all providers, Third Party Payers, utilization review agencies, my employer and state or federal agencies to exchange all demographic, medical, mental health, AIDS and HIV, and substance abuse information as necessary for claims processing, clinical studies, care management, plan administration, or benefit administration. I understand any information will be used only after issuance of plan coverage and will have no effect on determination of eligibility to enroll. I give this consent for myself and any eligible family member listed on this application for who I am authorized to do so. I understand that failure to sign this authorization may be a basis for enrollment or benefit denial. I understand that I am entitled to receive a copy of this authorization. I further understand that this authorization will remain in effect until coverage under the plan ends or I give written notice to carrier that I want to revoke this authorization. I understand the revocation of this authorization may be a basis for denying benefits.
*All plans renew Effective 1/1/21- the rates will change. Please refer to the benefit documents provided by Manpower for the new rates.
***Please print this form for your records before hitting submit.
You must be actively working to be eligible and enroll in benefits.