DOH/Form 116M 05/2014 Case Employer s Health Insurance Information A l This form MUST be completed by your employer or your company s Human Resources representative. Any blanks left on this form may delay the process. l A form must be completed for each employed household member. You may copy this form* l If you have general questions about this form or the medical programs please call 1-866-435-7414. General Information Employee Information Employee name first m*i. last Employee SSN EIN Phone Address street apt. city state zip Who can we contact about employee health coverage at this job Contact Name Phone Email address oYes oNo 1. Does your company offer health insurance If no skip to section D. Sign and return the form* 2. Is your health insurance a state employee benefit plan 4. Is the employee eligible to enroll in any insurance plan offered If no please explain If yes when is/was the employee eligible to enroll mm/dd/yy If yes name s of person s enrolled 6. Has this employee or a....
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How to fill out the UT DOH 116M online
The UT DOH 116M form is essential for collecting health insurance information for each employed household member. This guide will provide detailed, step-by-step instructions on how to accurately complete the form online.
Follow the steps to successfully complete the UT DOH 116M form.
- Press the ‘Get Form’ button to access the UT DOH 116M form and launch it in the online editor.
- Begin filling out the employee's information in the designated fields, including the employee's name, optional social security number or date of birth, and employer name.
- Indicate whether your company offers health insurance by selecting 'Yes' or 'No.' If 'No,' proceed to section E, sign, and submit the form.
- If the answer is 'Yes', specify when the company's enrollment period starts by entering the date in the format mm/dd/yy.
- In Section A, answer whether your company’s health plan meets the criteria listed. If it does, check 'Yes', and provide details on abortion coverage options as per your policy.
- Complete the chart in Section B with the details of the least expensive health plan available for the employee, noting monthly premium and yearly health plan deductible amounts.
- Proceed to Section C. Answer whether the employee is currently enrolled in a health insurance plan. If not enrolled, indicate eligibility to enroll and provide details if coverage was dropped or reduced in the last 90 days.
- In Section D, provide information about the employee's current health plan, including the names of persons enrolled, coverage start date, and insurance details.
- Review and confirm if the chosen health plan meets the specified coverage criteria in question 10 and fill out the remaining sections about monthly premiums and how often premiums are deducted.
- List any children with dental coverage as required, and then proceed to Section E to provide your printed name, phone number, signature, title, email address, and the date of signing.
- After ensuring all sections are completed accurately, save your changes. You can then download, print, or share the filled form as needed.
Complete your UT DOH 116M form online now for a quick and efficient submission!
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