Medical, Dental, Vision, FSA Enrollment/Declination & HSA Payroll Deduction Form

Please complete Sections 1 - 9

Email Address
Tell Us About You medical, Dental & Vision Insurance HSA* FSA* Payroll Deduction
Payroll Deduction
Check here if you are enrolling in: Please select plan year deduction
(per pay period)
Last Name First Name M.I. HEALTHCARE DEPENDENT CARE
MEDICAL DENTAL VISION □ $20
FSA** FSA
Home Address: Number and Street Apt. #/P.O. Box Plan year Plan year
□ $40
□ Individual deduction deduction
City State Zip Code □ Employee + Spouse □ Individual □ Individual
□ Employee + Child □ Employee + Spouse □ Employee + Spouse □ Other Amount $___________
HomeTelephone Work Telephone Cell Phone □ Family □ Employee + Child □ Employee + Child
□ Declined □ Family □ Family $____________ $______________
Employee Status (please check) □ Declined □ Declined
Marital Status (please check) Married ( ) Single ( ) Divorced ( ) Widowed ( )
FT ( ) PT ( )
*You cannot select a Healthcare FSA,
Declining Coverage YOU MUST COMPLETE AN OPTUM
if you are enrolled in the HSA

Medical ( ) Covered by other insurance ( )
Dental ( ) Covered by other insurance ( )
Check here if you are declining and provide a reason: HEALTH SAVINGS ACCOUNT
**REMEMBER - Over-the-Counter
Cannot afford Insurance ( ) Other ( ), If other, please explain APPLICATION
Medications require a Physican's
Cannot afford Insurance ( ) Other ( ), If other, please explain Prescription in order to be reimburseable.

Vision ( ) Covered by other insurance ( ) Cannot afford Insurance ( ) Other ( ), If other, please explain

Medical and/or
List All Family Members To Be Covered Dental and/or Relationship Gender(circle one) Date of Birth (MM/DD/YY) Social Security Number
Vision
Last Name First Name M.I. Dependent Up to Age 26
Your Name Med Dent Vis M F (circle Yes or No) / /

Spouse's
Med Dent Vis M F / /
Name

Dependent Med Dent Vis M F Y N / /

Dependent Med Dent Vis M F Y N / /

Dependent Med Dent Vis M F Y N / /

Dependent Med Dent Vis M F Y N / /


Do you or any member of your family have any other medical or dental coverage?
Yes No If yes, please fill in the information below.
Medicare Do you or any covered family member have
Medicare coverage? Yes No
Name of Other Insurance Company Name
Tell Us Is this person a retiree?
About Your Yes No
Other Name of Subscriber (policyholder) Medicare No. Effective Dates (MM/DD/YY)
Insurance Medicare A (Hospital) Medicare B (Medical)
/ / / /

The information here is complete and true. I understand that GSS and United Healthcare will rely on this information to enroll me and my dependents or to make changes to my membership. I understand that I should read the subscriber certificate or benefit booklet provided by my employer to understand
my benefits and any restrictions that apply to my health care plan. I understand that United Healthcare may obtain personal and medical information about me to carry out its business, and that it may use and disclose that information in accordance with law. I acknowledge that I may obtain further information
about the collection, use and disclosure of my information United Healthcare's notice of privacy practices.
Employee Signature Date (MM/DD/YY) / / Employer Signature Date (MM/DD/YY)

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