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California

Small Business Employee Enrollment

Form/Waiver of Coverage

Instructions Directory. Write the PCD name and Provider Number in
the area provided. You may choose a different Primary
Complete the information requested in each section Care Dentist for each enrolling member, however PCDs
according to the guidelines provided below. Please be
thorough and fill out all sections that apply. Submit the cannot be automatically assigned and are only required for
the Dental HMO plans.
completed enrollment form to your employer for processing.
Section A: Employee Information • Verify that spousal and domestic partner coverage is
• Please complete all information requested; available through your Employer.
• If enrolling in a UnitedHealthcare of California HMO plan, • Dependents are covered to age 26 and no full-time student
you must select a Primary Care Physician (PCP). Select status is required.
a PCP from the Provider Directory for yourself and each Section C: Product Selection
of your family members by writing the PCP name and • Benefit offerings are dependent on your employer
Provider Number in the area provided. You may choose a selections. Check with your employer for available plan
different PCP for each member of your family. options being offered to you.

PCP selection is only required if a UnitedHealthcare • Check the box for each plan in which you or your
SignatureValue (HMO), UnitedHealthcare dependents are enrolling.
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SignatureValue Advantage, SignatureValue Harmony,
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UnitedHealthcare SignatureValue Alliance, or • All enrolling family members must select the same medical
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UnitedHealthcare SignatureValue Focus plan is selected. and dental plan.
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If you do not select a PCP when selecting one of these • When selecting a UnitedHealthcare or UnitedHealthcare
plans, a PCP will be automatically assigned to you. Benefits Plan of California medical plan, write the three-
• If enrolling in a Dental HMO Plan, select a Primary Care digit or four-digit plan code of your selection in the space
Dentist (PCD) from the Dental Provider Directory for provided. For example: Plan Code GN-3.
yourself and each of your family members. Write the PCD • When selecting a UnitedHealthcare of California (HMO)
name and Provider Number in the area provided. You may plan, write the description of the plan you selected. For
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choose a different Primary Care Dentist for each enrolling example: UnitedHealthcare SignatureValue
member, however PCDs cannot be automatically assigned 20-40/250d.
and are only required for the Dental HMO plans.
Section D: Other Medical Insurance/Health Plan
Section B: Dependent Information Coverage Information
• Complete all information for each enrolling dependent, • If you, your spouse/domestic partner, or any dependent
including any enrolling dependent’s Social Security will be covered under any other medical insurance plan/
number. health plan, including Medicare, on the day this insurance/
• For each dependent enrolling in a UnitedHealthcare of health plan coverage begins, please complete this section.
California HMO Plan, select a Primary Care Physician If no other medical plan/coverage exists, please indicate
(PCP) from the Provider Directory by writing the PCP by checking NO.
name and Provider Number in the area provided. You may
choose a different PCP for each member in your family.
If you do not select a PCP when selecting one of these
plans, a PCP will be automatically assigned to you.
• For each dependent enrolling in a Dental HMO Plan,
select a Primary Care Dentist from the Dental Provider