Get Q Enrolling Enrollment/waiver Form (complete Sections I

Filling out the Q ENROLLING ENROLLMENT/WAIVER FORM is an essential step in managing your enrollment or waiver of coverage. This guide provides clear and detailed instructions on how to accurately complete the required sections of the form online.

Follow the steps to complete your form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred digital editor.
2. Begin by entering your employee or contract holder information. This section must be completed for both enrollees and waivers. Provide your effective date, employer/group name, full name (including middle initial), group number, payroll location, and social security number (indicate N/A if you do not have one). Also, fill in your address, city, state, zip code, and county.
3. Indicate your enrollment status by selecting either 'Active Employee' or 'Rehired Employee'. Next, mark your marital status by checking the appropriate box. Include your full-time hire or rehire date and gender, along with your home or cell number.
4. If applicable, indicate your COBRA continuant start date or HIPAA life event. Remember to attach a copy of the necessary documentation if relevant. State your hours worked per week, date of birth, and age.
5. For product selections, choose the medical product(s) you wish to enroll in and include the physician of record's full name along with their group practice. You also have options for vision and dental coverage. Confirm if you are an established patient.
6. If enrolling dependents, complete the dependent information section. List all the required details for each dependent, including relationship to you, birth date, and any necessary documentation for legal custodianship.
7. If waiving coverage, complete the waiver section only if you are declining coverage for yourself or your family members. Select the specific coverages you are declining and provide the reason for declining medical coverage, if applicable.
8. Complete the other health insurance coverage section. Include information about any additional insurance carriers and relevant dates.
9. Finally, ensure to provide the required authorized signature along with your printed name, employer/group name, and the date of signing. This confirms the accuracy of the provided information.
10. Once all sections are completed, save your changes. You have the option to download, print, or share the form as needed.

Complete your Q ENROLLING ENROLLMENT/WAIVER FORM online today for seamless processing of your coverage options.