If you DO NOT wish to be covered by the Celtic Healthy Texas plan, complete Sections A, B and H.

FOR OFFICE USE ONLY

CELTIC HEALTHY TEXAS EMPLOYEE ENROLLMENT FORM

Please complete all applicable fields on form. (Please print clearly.)

SECTION A: EMPLOYER NAME

SECTION B: EMPLOYEE INFORMATION

NAME (FIRST, MI, LAST) STREET ADDRESS BIRTH DATE WORK PHONE ( ) SEX M F RACE WHITE EMAIL BLACK HISPANIC ASIAN/PACIFIC ISLANDER DATE HIRED WHAT IS YOUR ANNUAL SALARY? AMERICAN INDIAN/ALASKAN NATIVE OTHER IS YOUR SPOUSE EMPLOYED? YES NO CITY MAIDEN NAME (IF APPLICABLE) STATE ZIP LANGUAGE PREFERENCE ENGLISH HOME PHONE ( ) SOCIAL SECURITY # SPANISH

IF CHANGING FROM INDIVIDUAL TO FAMILY COVERAGE TO ADD SPOUSE, GIVE DATE OF MARRIAGE MO / DAY / YR

FULL TIME PART TIME

SECTION C: DEPENDENT INFORMATION

NAME OF DEPENDENT (FIRST, MI, LAST MAIDEN NAME IF APPLICABLE) RELATIONSHIP TO EMPLOYEE STREET ADDRESS NAME OF DEPENDENT (FIRST, MI, LAST MAIDEN NAME IF APPLICABLE) RELATIONSHIP TO EMPLOYEE STREET ADDRESS NAME OF DEPENDENT (FIRST, MI, LAST MAIDEN NAME IF APPLICABLE) RELATIONSHIP TO EMPLOYEE STREET ADDRESS NAME OF DEPENDENT (FIRST, MI, LAST MAIDEN NAME IF APPLICABLE) RELATIONSHIP TO EMPLOYEE STREET ADDRESS NAME OF DEPENDENT (FIRST, MI, LAST MAIDEN NAME IF APPLICABLE) RELATIONSHIP TO EMPLOYEE STREET ADDRESS BIRTH DATE CITY STATE BIRTH DATE CITY STATE BIRTH DATE CITY STATE BIRTH DATE CITY STATE BIRTH DATE CITY STATE MALE FEMALE SOCIAL SECURITY # ZIP HOME PHONE ( MALE FEMALE SOCIAL SECURITY # ZIP HOME PHONE ( MALE FEMALE SOCIAL SECURITY # ZIP HOME PHONE ( MALE FEMALE SOCIAL SECURITY # ZIP HOME PHONE ( MALE FEMALE SOCIAL SECURITY # ZIP HOME PHONE ( ) ) ) ) )

SECTION D: GROUP INFORMATION

GROUP NUMBER GROUP NAME REQUESTED EFFECTIVE DATE

SECTION E: REASON FOR TRANSACTION

ADDING COVERAGE* New hire Annual open enrollment Other ENDING COVERAGE Termination of employment Change to other insurance Other CHANGES TO EXISTING COVERAGE** Individual Family Other Addition of a dependent (complete Dependent section above) Change in name, address, or other application information COBRA Other * If adding new coverage please attach a Qualifying Event Form ** If changing existing coverage attach a Change Form

TYPE OF COVERAGE EMPLOYEE ONLY EMPLOYEE AND SPOUSE EMPLOYEE AND CHILD(REN) EMPLOYEE AND FAMILY

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SECTION F: TERMS AND CONDITIONS FOR EMPLOYER COVERAGE

Thank you for choosing a Celtic Healthy Texas Plan for your health coverage. You will soon receive a New Member Kit in the mail. This kit will include information on your membership in the Celtic Healthy Texas Plan and your membership card(s). Also included in this kit will be information on how to obtain a Member Handbook/Certificate of Coverage, which defines your benefits and regulates benefit decisions. NOTE: The requested effective date may not be the actual effective date if it is not in accordance with the Celtic Healthy Texas Group Agreement and the Celtic Healthy Texas Plan Member Handbook/Certificate of Coverage. EMERGENCY CARE: Emergency services do not require referral or authorization. When you have an emergency medical condition, you should go to the nearest emergency department or call your local emergency communications system (police, fire department or 911). If you receive emergency care outside of the plan service area, the Celtic Healthy Texas Plan requires you to notify the plan within 48 hours or as soon as is medically possible. For more information on emergency benefits and plan procedures for emergency services, consult your Member Handbook/Certificate of Coverage. CONSENT: Submission of this form indicates that you authorize anyone who provides medical services to you, or your dependents to release to the plan any health information or medical records relating to those services for such routine needs as coordination of benefits, disease management programs, quality management, coordination of care, health services management, accreditation, processing and payment of related claims. AGREEMENT: I am employed by the company named on this form, working at least 30 hours per week, full time, or at least 20 hours part time. If full-time, I receive employer contribution to health insurance coverage. I hereby authorize my employer to deduct from my wages (if necessary) the amount I am responsible for contributing for the Celtic Healthy Texas Plan coverage. I understand that membership becomes effective in accordance with the Celtic Healthy Texas Plan Group Agreement and the Member Handbook/Certificate of Coverage. I have read these Terms and Conditions and understand how to obtain and use services under my Celtic Healthy Texas Plan coverage. I certify that all information is correct to the best of my knowledge. QUESTIONS ABOUT COVERAGE? Call Celtic Healthy Texas Plan Customer Service at 1-877-779-5229, or visit our website at http://www.MyHealthyTexas.com.
EMPLOYEE NAME: EMPLOYEE SIGNATURE: DATE:

SECTION G: OTHER MEDICAL COVERAGE

Prior Medical Insurance Information This section must be completed to receive credit for prior medical coverage. Within the last 12 months, have you, your spouse, or your dependents had any other medical coverage? NO YES (if yes, please complete this section.) Employee Spouse Child(ren) Family Prior medical carrier name _____________________________________________ Effective date ____ /____ /____ End date ____ /____ /____ Prior coverage type:

Other Medical Coverage Information On the day this coverage begins, will you, your spouse or any of your dependents be covered under any other medical health plan or policy or Medicare? YES (continue completing this section) NO (skip the rest of this section)

Name of other carrier ______________________________________________________ Other Group Medical Coverage Information Effective Date ____ /____ /____ End Date ____ /____ /____ Name and date of birth of policyholder for other coverage:
EMPLOYEE: SPOUSE NAME: DEPENDENT NAME: DEPENDENT NAME: DEPENDENT NAME: COVERED BY OTHER INSURANCE: COVERED BY OTHER INSURANCE: COVERED BY OTHER INSURANCE: COVERED BY OTHER INSURANCE: COVERED BY OTHER INSURANCE: YES YES YES YES YES NO NO NO NO NO

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SECTION H: WAIVER/VERIFICATION OF ALTERNATE COVERAGE

I decline all coverage for: Myself Spouse Dependent Children Individual Plan VA Eligibility Myself and all dependents Covered by Medicare Medicaid Declining coverage due to existence of other coverage: Spouses Employers Plan COBRA from Prior Employer I (we) have no other coverage at this time

Other ____________________________________ I (name) ______________________________________ , certify that I am an employee of and that I am eligible for group health care coverage through (employer name) ______________________________________ , my employer. I also certify that I am waiving my right to group health care coverage through my employer at this time because I have chosen health care coverage through: a parent or spouse, union, Medicaid, Champus, or Medicare, or another federal program, another group health program or other health insurance coverage. I affirm that the assertions stated above are true and complete to the best of my knowledge. I understand that by waiving coverage at this time, I will not be allowed to participate unless I qualify at a special enrollment period or as a late enrollee, if applicable, or at the next open enrollment period.
EMPLOYEE NAME: EMPLOYEE SIGNATURE: SIGNATURE OF AUTHORIZED COMPANY REPRESENTATIVE:

FAX this enrollment form and all other forms to 1-888-564-6847.

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