Enrollment Forms. Each employee who completes the required enrollment form(s) will receive the health, dental and vision insurance benefits in accordance with the following eligibility:
Enrollment Forms. Parents will be asked to complete the following: Enrollment Agreement (return with $25.00 registration fee, $20.00 required membership fee, if new member. Arc members check to see if fees are paid.) Enrollment Form (5 pages) Emergency Information Form Medication Authorization TDFPS Admission Information Parental Emergency Medical Consent Physical Assessment & Health Form Release of Liability Form Immunization Record The Program expects the forms to be kept current. The parent must provide new information to the Staff regarding information on forms such as: Emergency contact person(s) - Employer’s phone numbers - Arrival/departure changes
Enrollment Forms. As the custodian of records for the Association Membership, the Association will be responsible for distributing and collecting any forms related to membership dues, general assessments and/or payment for any membership benefit program. Any forms that are submitted directly to the County from an employee shall be forwarded to the Association. The Association shall provide to the County a certified list of employees who have authorized a payroll deduction for dues and/or fees to the Association.
Enrollment Forms. BlueCross shall enroll those individuals who have completed an enrollment form for the health plan, and are identified by the Employer as eligible for benefits under the HRA Plan on the effective date of the HRA Plan, and subsequently during the continuance of this Agreement. The Employer shall provide BlueCross with enrollment information in a mutually agreeable format, (i.e., electronically, faxed, paper, etc.). BlueCross is not responsible for verifying data submitted by Employer. BlueCross shall be entitled to rely on the information furnished to it by the Employer, and the Employer shall hold BlueCross harmless for inaccurate information provided by the Employer or the Employer’s failure to provide such information in a timely manner.
Enrollment Forms. As the custodian of records for BTC Membership, BTC is responsible for distributing and collecting any forms related to membership dues, general assessments and/or payment for any membership benefit program. The County shall forward directly to BTC any forms submitted to the County by an employee. BTC shall provide the County with a certified list of employees who authorized dues payroll deductions to BTC.
Enrollment Forms. A new employee and all current employees must annually complete and return insurance enrollment forms before claims can be processed. A new employee must complete an insurance application form before his/her initial coverage will be in effect.
Enrollment Forms. As the custodian of records for ACWFIA Membership, ACWFIA will be responsible for distributing and collecting any forms related to membership dues, general assessments and/or payment for any membership benefit program. Any forms that are submitted directly to the County from an employee shall be forwarded to the applicable employee organization. ACWFIA shall provide to the County a certified list of employees who have authorized a payroll deduction for dues to ACWFIA.
Enrollment Forms. As the custodian of records for the ACMEA (Sheriff's Sworn Unit) Membership, the ACMEA (Sheriff's Sworn Unit) will be responsible for distributing and collecting any forms related to membership dues, general assessments and/or payment for any membership benefit program. Any forms that are submitted directly to the County from an employee shall be forwarded to ACMEA. ACMEA (Sheriff's Sworn Unit) shall provide to the County a certified list of employees who have authorized a payroll deduction for dues to ACMEA (Sheriff's Sworn Unit).
Enrollment Forms. Original enrollment forms shall be maintained by the MCO.
Enrollment Forms. It is a requirement of licensing that all enrollment forms must be complete and turned in to the center prior to or on the day of enrollment. This must be done to keep us incompliance with the licensing department of the state of Texas. I have read the “Parent Agreement” information and understand the terms of enrollment. Parent Signature:
