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Enrolling in any of the plans is simple. Once you have reviewed all of the information for each plan, which is found under the appropriate benefit offered on this website as medical, dental, vision or life, simply click on the appropriate enrollment form in this section, print it, then complete and sign the form. See below for instructions on submitting your enrollment form(s).
Medical and Life Plan Enrollment
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The Blue Shield Enrollment Application can be used for enrolling in the medical and life plans and for making changes once you are enrolled. Instructions on how to complete the form are also attached. Please Note – You have four medical plan options; 1) Trio HMO, 2) Access+ HMO, 3) HSA PPO or 4) Full PPO (Please note the HSA plan is called a "Full PPO Savings HSA" on the enrollment application) . Please complete the form in its entirety and sign/date it where indicated.
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Dental and Vision Plan Enrollment
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The Premier Access Enrollment Application can be used for enrolling in the dental and vision plans and for making changes once you are enrolled. Please complete the form in its entirety and sign/date it where indicated.
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2019 Payroll Deduction Authorization
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In order to view the per-pay-period deduction amounts for the medical, dental and vision plans, please click on the 2018 Payroll Deduction Authorization Form to the left. If you choose to enroll in any of the plans, please print, complete and sign the form and submit to Human Resources.
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Waiving the Plans- Completing the Refusal of Coverage Form
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If you are covered by another plan(s) or simply choose to not enroll in any, or all, of the benefit plans offered, please complete the Refusal of Coverage Form in the appropriate sections. Please note that when you are covered by another health plan and decline coverage, if the other coverage is lost, you may qualify to enroll in the Office Solutions benefit plans. In order to do so, you would need to provide a letter from either the previous carrier or other employer providing the coverage, stating the type of coverage and the date coverage was lost. You must complete and submit the enrollment form(s) for the coverage you desire within 30 days of the loss of coverage in order to be eligible for the plans. Failure to do so would disallow enrollment until the next open enrollment period.
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Changing Your Enrollment
Once you have made your benefit plan decisions, you cannot change your enrollment until open enrollment for the following benefit plan year, unless you experience a qualifying (life) event, such as marriage, divorce, birth of a child, adoption of a child or placement for adoption. If you experience a qualifying event and wish to make a change to your enrollment by adding or deleting coverage, the change must occur within 30 days of the date of the qualifying event.
If you have experienced a qualifying event, in order to make a change to your medical enrollment, you would use the enrollment/change forms. This form allows you to add or delete eligible dependents, as well as indicate other changes, as a name, address or Primary Care Physician change.
If you have experienced a qualifying event, in order to make a change to your medical enrollment, you would use the enrollment/change forms. This form allows you to add or delete eligible dependents, as well as indicate other changes, as a name, address or Primary Care Physician change.
Questions?
For questions about claims, please click on Important Plan/Contract Information under the appropriate line of coverage for the customer service contact number.
For questions regarding plan eligibility, benefits or enrollment forms, contact Thomas Lambert at Ashbrook Clevidence.
Phone: (714) 979-4023
Fax: (714) 979-2809
Email: TomL@aclevidence.com
We thank you for the opportunity to be of service to you and your family!
For questions regarding plan eligibility, benefits or enrollment forms, contact Thomas Lambert at Ashbrook Clevidence.
Phone: (714) 979-4023
Fax: (714) 979-2809
Email: TomL@aclevidence.com
We thank you for the opportunity to be of service to you and your family!
