Health Insurance and Optional Enrollment Application

INSTRUCTIONS: ALABAMA HEALTH INSURANCE AND OPTIONAL ENROLLMENT APPLICATION

Alabama public education employees who wish to enroll in the state's health insurance plan known as PEEHIP do so using the form discussed in this article. This document can be obtained from the website of the Retirement Systems of Alabama.

Alabama Health Insurance And Optional Enrollment Application Step 1: Indicate with a check mark whether you are an active member or retired.

Alabama Health Insurance And Optional Enrollment Application Step 2: The first section concerns subscriber information. Enter your Social Security number, full name, mailing address, date of birth, home and work phone numbers, gender, marital status, the name of your employer and school system, your email address and date of employment.

Alabama Health Insurance And Optional Enrollment Application Step 3: Indicate with a check mark whether you or your spouse have made use of tobacco products within the last 12 months.

Alabama Health Insurance And Optional Enrollment Application Step 4: The next section concerns the type of coverage you are seeking. Indicate with a check mark whether you are applying for hospital/medical coverage, supplemental hospital/medical coverage, or a VIVA health plan. If the latter, indicate with a check mark whether you are seeking it as a single person or for a family.

Alabama Health Insurance And Optional Enrollment Application Step 5: Indicate with check marks all additional optional coverages you are seeking and enter your requested effective date.

Alabama Health Insurance And Optional Enrollment Application Step 6: The next section requires anyone seeking family coverage to document their dependents. Enter each dependent's name, Social Security number and date of birth. Indicate their gender and relationship to you with check marks.

Alabama Health Insurance And Optional Enrollment Application Step 7: The next section is to be completed if seeking PEEHIP Supplemental coverage or if you or your dependents currently have other group health, dental or vision coverage in effect.

Alabama Health Insurance And Optional Enrollment Application Step 8: The next section must be completed if you or your dependents are eligible for Medicare.

Alabama Health Insurance And Optional Enrollment Application Step 9: The next section is only for completion by PEEHIP members who retired after September 30, 2005.

Alabama Health Insurance And Optional Enrollment Application Step 10: Sign and date the bottom of the form.

Health Insurance and Optional Status Change

INSTRUCTIONS: ALABAMA HEALTH INSURANCE AND OPTIONAL STATUS CHANGE

Alabama public education employees who are already enrolled in the state insurance program known as PEEHIP can use the form discussed in this article to make changes to their insurance coverage, as well as to certify or change their tobacco usage status. This document can be obtained from the website maintained by the Retirement Systems of Alabama.

Alabama Health Insurance And Optional Status Change Step 1: Indicate with a check mark whether you are an active or retired member.

Alabama Health Insurance And Optional Status Change Step 2: The first section requires information about the subscriber. Enter your Social Security or PID number, full name, date of birth and daytime phone number. Indicate your marital status with a check mark.

Alabama Health Insurance And Optional Status Change Step 3: Indicate with check marks whether you or your spouse have used tobacco in the last 12 months.

Alabama Health Insurance And Optional Status Change Step 4: If you have changed your name or employers, give your new name and/or date of employment transfer.

Alabama Health Insurance And Optional Status Change Step 5: In the next section, indicate with check marks the changes you are requesting to be made.

Alabama Health Insurance And Optional Status Change Step 6: Enter the date you are requesting that the changes take effect.

Alabama Health Insurance And Optional Status Change Step 7: In the next section, indicate with check marks the reason for these requested changes.

Alabama Health Insurance And Optional Status Change Step 8: The next section concerns documentation of dependents and is only to be completed if seeking family coverage.

Alabama Health Insurance And Optional Status Change Step 9: The next section is only to be completed if you have the PEEHIP Supplemental Plan or other currently in effect group health, dental or vision coverage.

Alabama Health Insurance And Optional Status Change Step 10: The next section must be completed if you or your dependents are eligible for Medicare.

Alabama Health Insurance And Optional Status Change Step 11: The next section is only to be completed if you retired after September 30, 2005.

Alabama Health Insurance And Optional Status Change Step 12: Sign and date the bottom of the page. Mail the completed document to the address at the top of the first page.

Southland National Vision Claim Form

INSTRUCTIONS: SOUTHLAND VISION CLAIM FORM

Alabama public employees who are enrolled with Southland Benefit Solutions health insurance use the vision claim form discussed in this article to file for coverage for a vision health appointment. This document can be obtained from the website of Southland Benefit.

Southland Vision Claim Form Step 1: The top half of the form is to be completed by you. In box 1, indicate with a check mark whether you are enrolled with Medicare, Medicaid, a group health plan or other. Give the number of your plan in box 1a.

Southland Vision Claim Form Step 2: Enter the patient's name in box 2. Enter the last name first, followed by the first name and middle initial.

Southland Vision Claim Form Step 3: Enter the patient's birth date in box 3.

Southland Vision Claim Form Step 4: Enter the insured's name in box 4.

Southland Vision Claim Form Step 5: Enter the patient's address in box 5.

Southland Vision Claim Form Step 6: Indicate the patient's relationship to the insured with a checkmark in box 6.

Southland Vision Claim Form Step 7: Enter the insured's street address, city, state, zip code and telephone number including area code in box 7.

Southland Vision Claim Form Step 8: Indicate the patient's status with a checkmark in box 8. Choose from "single," "married," "other," "employed," "full-time student" and "part-time student" as appropriate.

Southland Vision Claim Form Step 9: In boxes 10 through 10d, give the insured's group policy or FECA number, employer's or school name, insurance plan or program name, and indicate if there is another health benefit plan. If so, complete boxes 9 through 9d.

Southland Vision Claim Form Step 10: The patient or an authorized person should sign box 11.

Southland Vision Claim Form Step 11: The insured or an authorized person should sign box 12.

Southland Vision Claim Form Step 12: The remainder of the form should be submitted to the office of the vision physician or supplier in question. This office will be responsible for completing and submitting the form.

Southland Vision Claim Form Step 13: This form must be submitted by the physician or supplier to Southland within 365 days of the date of service. The address to which this form should be submitted can be found at the top of the page.

Southland National Dental Claim Form

INSTRUCTIONS: SOUTHLAND DENTAL CLAIM FORM

Alabama public employees who have dental insurance from Southland Benefit Solutions use the dental claim form discussed in this article after having a dental appointment. This document can be obtained from the website maintained by Southland Benefit.

Southland Dental Claim Form Step 1: In box 1, check all applicable boxes concerning the type of transaction this claim covers.

Southland Dental Claim Form Step 2: In box 2, enter the predetermination/preauthorization number if applicable.

Southland Dental Claim Form Step 3: In box 3, give the name, address, city, state and zip code of your insurance company or dental benefit plan.

Southland Dental Claim Form Step 4: Indicate with a checkmark in box 4 whether you have other dental or medical coverage. If no, skip to box 12.

Southland Dental Claim Form Step 5: If you have other medical or dental coverage, give the name of policyholder or subscriber in box 5, enter their date of birth in box 6, check the box next to their gender in box 7, give their policy or subscriber ID in box 8, the plan or group number in box 9, indicate the patient's relationship to the policyholder in box 10 with a checkmark, and give the company or benefit plan's name, address, city state and zip code in box 11.

Southland Dental Claim Form Step 6: In box 12, enter the policyholder or subscriber name, street address, city, state and zip code for the policy listed in box 3.

Southland Dental Claim Form Step 7: In box 13, give their date of birth.

Southland Dental Claim Form Step 8: In box 14, indicate their gender with a checkmark.

Southland Dental Claim Form Step 9: In box 15, give their policy or subscription identification number.

Southland Dental Claim Form Step 10: In box 16, give the plan or group number.

Southland Dental Claim Form Step 11: Give the employer name in box 17.

Southland Dental Claim Form Step 12: Provide all information requested about the patient in boxes 18 through 23.

Southland Dental Claim Form Step 13: Boxes 24 through 35 should be filled out by the office which performed the services in question.

Southland Dental Claim Form Step 14: The patient or guardian, as well as the subscriber, should sign and date the left hand bottom corner of the page where indicated.

Southland National Indemnity and Cancer Claim Form

INSTRUCTIONS: SOUTHLAND NATIONAL INDEMNITY AND CANCER CLAIM FORM

Alabama public employees who are treated in a hospital or for cancer use the claim form discussed in this article to file a claim for coverage with Southland Benefits. This document can be obtained from the website of the Retirement Systems of Alabama.

Southland National Indemnity And Cancer Claim Form Step 1: Enter the subscriber's name in box 1.

Southland National Indemnity And Cancer Claim Form Step 2: Enter the subscriber's contract number in box 2.

Southland National Indemnity And Cancer Claim Form Step 3: Enter the subscriber's home address in box 3.

Southland National Indemnity And Cancer Claim Form Step 4: Enter the patient's name in box 4.

Southland National Indemnity And Cancer Claim Form Step 5: Enter the patient's date of birth in box 5 and their age in box 6.

Southland National Indemnity And Cancer Claim Form Step 6: Indicate the patient's sex with a checkmark in box 7.

Southland National Indemnity And Cancer Claim Form Step 7: Indicate the patient's relationship to the subscriber with a checkmark in box 8.

Southland National Indemnity And Cancer Claim Form Step 8: Enter the subscriber's home and work phone numbers in box 9.

Southland National Indemnity And Cancer Claim Form Step 9: In box 10, provide a written summary of the type of illness or injury, or the doctor's diagnosis.

Southland National Indemnity And Cancer Claim Form Step 10: Enter the physician's name and address, the name of the hospital if confined, the date of admission and discharge, the date the accident or the sickness began, the date on which the first treatment was administered, and indicate whether the condition was related to an accident or illness. Specify the type of accident or illness.

Southland National Indemnity And Cancer Claim Form Step 11: Sign and date the top half of the form.

Southland National Indemnity And Cancer Claim Form Step 12: Give the form to the supervising doctor. They will fill out the attending physician's statement and return the form to you.

Southland National Indemnity And Cancer Claim Form Step 13: Obtain an itemized copy of the hospital bill and attach it to the claim form.

Southland National Indemnity And Cancer Claim Form Step 14: Mail the form and bill to Southland Benefits Administration via the address given on the second page.

MedImpact Prescription Drug Claim Form

INSTRUCTIONS: MEDIMPACT PRESCRIPTION DRUG CLAIM FORM

Alabama public employees enrolled in the PEEHIP health insurance program use the prescription drug claim form discussed in this article to obtain coverage for their prescription drug purchases. This document can be obtained from the website of the Retirement Systems of Alabama.

MedImpact Prescription Drug Claim Form Step 1: The first section requires information about the primary member or cardholder. In the first two boxes, give their ID number and full name.

MedImpact Prescription Drug Claim Form Step 2: In the next three lines, provide the name of the health plan or insurance, the member's daytime phone number, and the member's evening phone number.

MedImpact Prescription Drug Claim Form Step 3: In the next four boxes, provide the member's street address, city, state and zip code.

MedImpact Prescription Drug Claim Form Step 4: The next section should only be filled out if the patient is not the same as the primary member or cardholder. In the first two boxes, enter the patient's name and date of birth.

MedImpact Prescription Drug Claim Form Step 5: Indicate the patient's relationship to the primary member or cardholder with a checkmark.

MedImpact Prescription Drug Claim Form Step 6: Enter the patient's street address, city, state and zip code in the next four boxes.

MedImpact Prescription Drug Claim Form Step 7: If you have any other coverage, enter its name.

MedImpact Prescription Drug Claim Form Step 8: If you have worker's compensation, stop filling out this form and submit your claims to your employer.

MedImpact Prescription Drug Claim Form Step 9: The next section requires details about all prescriptions relevant to this claim. You may either complete this section yourself and submit it with supporting prescription labels and receipts or have your pharmacist complete this section.

MedImpact Prescription Drug Claim Form Step 10: The claimant should sign the form where indicated at the top of the first page.

MedImpact Prescription Drug Claim Form Step 11: The final section concerns compound prescriptions and can only be completed by a pharmacist.

MedImpact Prescription Drug Claim Form Step 12: When submitting this form, it must be accompanied the original prescription label or receipt. Copies are not acceptable. Submit to the claim and prescription labels or receipts to the address at the top of the first page.

Provider Screening Form IB13

INSTRUCTIONS: ALABAMA PROVIDER SCREENING FORM (Form IB13)

Alabama state employees who choose not to participate in Worksite Wellness screenings may instead submit health screening results through a healthcare provider. This is done using a form IB13. This document can be obtained from the website of the Alabama State Employees' Insurance Board.

Alabama Provider Screening Form IB13 Step 1: Section 1 should be completed by the employee. In the first blank box, enter your name.

Alabama Provider Screening Form IB13 Step 2: In the second blank box, enter the screening date.

Alabama Provider Screening Form IB13 Step 3: In the third blank box, indicate whether you are male or female with a check mark.

Alabama Provider Screening Form IB13 Step 4: In the fourth blank box, enter your age.

Alabama Provider Screening Form IB13 Step 5: In the fifth blank box, enter your contract number.

Alabama Provider Screening Form IB13 Step 6: In the sixth blank box, enter your Social Security number.

Alabama Provider Screening Form IB13 Step 7: In the seventh blank box, enter your date of birth.

Alabama Provider Screening Form IB13 Step 8: In the eighth blank box, enter your daytime telephone number.

Alabama Provider Screening Form IB13 Step 9: Indicate your race or ethnicity with a check mark.

Alabama Provider Screening Form IB13 Step 10: Indicate with a check mark whether you have or have been told you have high cholesterol, high blood pressure or diabetes.

Alabama Provider Screening Form IB13 Step 11: Indicate with a check mark whether you take any medication for the conditions listed in step 10.

Alabama Provider Screening Form IB13 Step 12: The second section should be completed by your health care provider. They will detail your blood pressure, total cholesterol, HDL and LDL cholesterol, triglycerides, blood glucose, height, weight, body mass index, waist measurement, and waist/height ratio.

Alabama Provider Screening Form IB13 Step 13: On the next blank line, the provider should print their name.

Alabama Provider Screening Form IB13 Step 14: On the next blank line, the provider should enter their signature.

Alabama Provider Screening Form IB13 Step 15: On the next blank line, the provider should enter their address.

Alabama Provider Screening Form IB13 Step 16: The completed form should be returned to the State Employees' Insurance Board at the address given at the bottom of the page.

Wellness Discount Certification Form IB07

INSTRUCTIONS: ALABAMA WELLNESS DISCOUNT CERTIFICATION FORM (Form IB07)

Alabama state employees who have participated in a worksite wellness screening and have since taken correctly documented steps to control identified health risks may apply for a wellness premium discount on their health insurance coverage by filing a form IB07. This document can be obtained from the website of the Alabama State Employees' Insurance Board.

Alabama Wellness Discount Certification Form IB07 Step 1: In the first blank box, enter the member name.

Alabama Wellness Discount Certification Form IB07 Step 2: In the second blank box, indicate with a check mark whether you are male or female.

Alabama Wellness Discount Certification Form IB07 Step 3: In the third blank box, enter your age.

Alabama Wellness Discount Certification Form IB07 Step 4: In the fourth blank box, enter your contract number.

Alabama Wellness Discount Certification Form IB07 Step 5: In the fifth blank box, enter your Social Security number.

Alabama Wellness Discount Certification Form IB07 Step 6: In the sixth blank box, enter your date of birth.

Alabama Wellness Discount Certification Form IB07 Step 7: In the seventh blank box, enter your daytime telephone number, including the area code.

Alabama Wellness Discount Certification Form IB07 Step 8: Check the first box if you were counseled by a health provider. You must attach either a wellness program office visit referral or a completed provider screening form documenting results. Indicate which with a check mark.

Alabama Wellness Discount Certification Form IB07 Step 9: Check the fourth box if you participated in a Physician Supervised Weight Management program. Enter the name and phone number of the program and the dates on which you attended.

Alabama Wellness Discount Certification Form IB07 Step 10: Check the fifth box if you participated in a SEIB Fitness Center's wellness program. Enter the name and phone number of the program, the dates you attended and a program description.

Alabama Wellness Discount Certification Form IB07 Step 11: Check the sixth box if you self-managed your health risks. You must attach valid proof.

Alabama Wellness Discount Certification Form IB07 Step 12: You must submit this form to the Alabama State Employees' Insurance Board no later than November 30th. Incomplete forms will not be processed and will be returned. Mail the form to the address given at the bottom of the page.

COBRA Form 11 IB11

INSTRUCTIONS: ALABAMA COBRA EMPLOYER NOTICE MEMO (Form IB11)

When an Alabama state employee enrolled in the state's SEHIP retirement plan is terminated, dies, has a reduction in hours or becomes eligible for Medicare, their employer must file a form IB11. This form is available on the website maintained by the Alabama State Employees' Insurance Board. Note that instead of filing this memo, you may choose to file a form 11 instead. Further assistance may be obtained by calling the telephone number given at the bottom of the page.

Alabama COBRA Employer Notice Memo IB11 Step 1: On the first blank line, enter the name of the employee.

Alabama COBRA Employer Notice Memo IB11 Step 2: On the second blank line, enter the Social Security number of the employee.

Alabama COBRA Employer Notice Memo IB11 Step 3: On the third blank line, enter the number and street or P.O. box of the employee.

Alabama COBRA Employer Notice Memo IB11 Step 4: On the fourth blank line, enter the city, state and zip code of the employee.

Alabama COBRA Employer Notice Memo IB11 Step 5: On the fifth blank line, enter the name of the employer.

Alabama COBRA Employer Notice Memo IB11 Step 6: If the employee has been terminated for any reason other than gross misconduct, check line 1. Enter the date of their termination.

Alabama COBRA Employer Notice Memo IB11 Step 7: If the employee has had their hours reduced, including a reduction in leave without pay, check line 2. Enter the date on which the reduction took effect.

Alabama COBRA Employer Notice Memo IB11 Step 8: If the employee has died, check line 3. Enter the date of death.

Alabama COBRA Employer Notice Memo IB11 Step 9: If the employee has become eligible for Medicare, check line 4. Enter the date on which they become eligible. Note that this will only affect medical coverage. Dental, prescription or vision care coverage will remain in effect.

Alabama COBRA Employer Notice Memo IB11 Step 10: On the next blank line, enter the date.

Alabama COBRA Employer Notice Memo IB11 Step 11: On the next blank line, the employer should enter their name.

Alabama COBRA Employer Notice Memo IB11 Step 12: Mail the form to the address given at the bottom of the page. You may also fax it to the number given.

Dependent Premium Conversion Plan – for Open Enrollment IB08

Insurance

Annual Tobacco User Premium Discount Application IB06

Non-Tobacco User Discount Application IB05