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Health Insurance Enrollment IB02 – New employees only

Health Insurance Enrollment IB02 - New employees only

 

INSTRUCTIONS: ALABAMA HEALTH INSURANCE ENROLLMENT FORM (Form IB02)

 

 

Alabama state employees file for health insurance for themselves and qualifying dependents using a form IB02. This document can be obtained from the website of the Alabama State Employees' Insurance Board.

 

Alabama Health Insurance Enrollment Form IB02 Step 1: Indicate with a check mark if you are filing for basic medical coverage, secondary supplemental coverage, optional policies for vision, dental and hospital indemnity, or if you are declining coverage.

 

Alabama Health Insurance Enrollment Form IB02 Step 2: Enter your full name and sex.

 

Alabama Health Insurance Enrollment Form IB02 Step 3: Enter your Social Security number and date of birth.

 

Alabama Health Insurance Enrollment Form IB02 Step 4: Enter your street address, city, state and zip code.

 

Alabama Health Insurance Enrollment Form IB02 Step 5: Enter your home and work telephone numbers, as well as your email address.

 

Alabama Health Insurance Enrollment Form IB02 Step 6: Enter the date on which you are requesting that coverage take effect for dependents.

 

Alabama Health Insurance Enrollment Form IB02 Step 7: The next section requires you to list all dependents you are seeking coverage for. Enter their name, indicate their relationship to you with a check mark, and provide their date of birth and Social Security number. Note that you cannot obtain coverage for a divorced or common-law spouse.

 

Alabama Health Insurance Enrollment Form IB02 Step 8: If you have additional group health insurance, indicate whether it has a spousal-carve out.

 

Alabama Health Insurance Enrollment Form IB02 Step 9: Enter the name of the company providing this insurance.

 

Alabama Health Insurance Enrollment Form IB02 Step 10: Enter the name of the contract holder and the policy number.

 

Alabama Health Insurance Enrollment Form IB02 Step 11: Enter the group number and the name of the employer providing this insurance.

 

Alabama Health Insurance Enrollment Form IB02 Step 12: Indicate with a check mark whether this plan includes dental coverage. If so, you must give the name of the dental insurance company, the policy and group number, and the name of the providing employer.

 

Alabama Health Insurance Enrollment Form IB02 Step 13: The section at the bottom left should be completed by your current employer.

 

Alabama Health Insurance Enrollment Form IB02 Step 14: Sign and date the form at the bottom right.

 

Download the PDF file .

Provider Screening Form IB13

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.

Download the PDF file .

Wellness Discount Certification Form IB07

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.

Download the PDF file .

COBRA Form 11 IB11

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. 

Download the PDF file .

Plan Change Form State Employee IB14

Plan Change Form State Employee IB14

 

INSTRUCTIONS: ALABAMA STATE EMPLOYEE PLAN CHANGE FORM (Form IB14)

 

 

Alabama state employees who wish to change their health insurance coverage do so by filing a form IB14. This form can be obtained from the website of the Alabama State Employees' Insurance Board.

 

Alabama State Employee Plan Change Form IB14 Step 1: At the top of the form, check the box next to the type of coverage you are seeking to obtain, or indicate if you are declining coverage.

 

Alabama State Employee Plan Change Form IB14 Step 2: On the first line enter your name, sex and the date on which coverage took effect.

 

Alabama State Employee Plan Change Form IB14 Step 3: On the second line enter your contact telephone number and date of birth.

 

Alabama State Employee Plan Change Form IB14 Step 4: On the third line enter your street address.

 

Alabama State Employee Plan Change Form IB14 Step 5: On the fourth line enter your city, state and zip code.

 

Alabama State Employee Plan Change Form IB14 Step 6: On the fifth line enter your home and work telephone numbers, as well as your email address.

 

Alabama State Employee Plan Change Form IB14 Step 7: The next four blank lines are provided to document dependents you are seeking coverage for. This is only required for those seeking basic coverage (SEHIP). On the first line, enter your spouse's name, birthdate and Social Security number.

 

Alabama State Employee Plan Change Form IB14 Step 8: On the next three lines, enter the same information for your children. Indicate their relationship to you by circling the appropriate label in the second column. 

 

Alabama State Employee Plan Change Form IB14 Step 9: If you are applying for supplemental coverage or Southland optional policies for vision, dental or cancer care or hospital indemnity, you must complete the last section documenting your primary insurance coverage. The first question asks you if this primary coverage has a spousal carve-out. Indicate "Yes" or "No" by circling the applicable response.

 

Alabama State Employee Plan Change Form IB14 Step 10: Provide all identifying information required about your health insurance company, as well as any dental coverage you have.

 

Alabama State Employee Plan Change Form IB14 Step 11: Sign and date the form. Mail it to the address given at the bottom of the second page.

Download the PDF file .