Health Election: Medical, Dental, Vision

_____________________________________________________________________________________________________________________________________

Relationship

Birth Date Gender

Address different

Choose coverage for

each eligible dependent

to Employee

(use codes

from employee?

Social Security Number

(required)

Medical Dental Vision

Name

on reverse)

M/D/Y AGE M F YES NO YES NO YES NO YES NO

Employee (named in SECTION I)

Health Election

Medical, Dental, Vision

SECTION I: PERSONAL INFORMATION

Employee’s Full Name First M.I. Last OSU Employee ID Number

Email Address Daytime Phone Number

SECTION 2: REASON FOR COMPLETING FORM

Date of event: _____ / _____ / _____ (return form within 30 days of event date or by annual open enrollment deadline)

Qualifying status change (please specify)

Hired Divorce/Dissolution

Change in Dependent Eligibility

Newly Eligible Birth/Adoption/Legal Guardianship

Termination of Sponsored Dependent Coverage

Open Enrollment Loss of Other Coverage

Gained Eligibility for Other Coverage

Marriage

Other

(describe):_________________________________________________________________________________________________________________

Refer to Speciﬁc Plan Details document(s) for additional details.

Documentation may be required.

SECTION 3: HEALTH PLAN COVERAGE SELECTION

A. I

Prime Care Advantage

Prime Care Choice Out -of -Area

3, 4

elect medical coverage—make selection below:

Medical coverage level:

Employee only Employee + Spouse

Employee + Children Family

I waive medical coverage

Prime Care Connect—Special eligibility rules apply for enrollment in this medical coverage. Application requires proof of qualifying

household income. Refer to the Prime Care Connect Application Guide online at hr.osu.edu/beneﬁts/medical. Contact OSU Health Plan at

614-292-4700 or 800-678-6269 to apply. To ensure medical coverage, you are encouraged to elect one of the other medical coverage

options listed on this form. If your eligibility for Prime Care Connect is veriﬁed, your enrollment will be automatically transferred to

that coverage.

Special application required for individual access to out-of-area coverage.

Premium at Prime Care Advantage rate; eligibility based on qualifying zip code.

B. I

Dental Basic

Dental Plus

elect dental coverage—make selection below:

Dental coverage level:

Employee only Employee + Spouse

Employee + Children Family

I waive dental coverage

C. I

Vision Basic

Vision Plus

elect vision coverage—make selection below:

Vision coverage level:

Employee only Employee + Spouse

Employee + Children Family

SECTION 4 -A: EMPLOYEE AND ELIGIBLE DEPENDENT ENROLLMENT INFORMATION

Please list self and all family members to whom new coverage or coverage changes will apply. (Use chart on reverse if additional space is needed.)

Please use the numbers and letters on reverse to indicate Relationship to Employee. Review dependent eligibility guidelines online at

hr.osu.edu/beneﬁts/dependent-eligibility-guidelines.

If dependent’s address differs from employee’s address, provide dependent’s address in SECTION 6.

SECTION 5: AUTHORIZATION

I have read and understand the materials describing the terms and conditions of The Ohio State University Faculty and Staff Health Plan, The Ohio State University Faculty

and Staff Vision Plan, and The Ohio State University Faculty and Staff Dental Plan, and agree to such terms and conditions. I declare that any individual for whom I am

requesting health coverage as my dependent meets the deﬁnition of an eligible dependent as stated in the Dependent Eligibility Guidelines, available online at hr.osu.

edu/beneﬁts/dependent-eligibility-guidelines. I understand that the university has the ability to rescind (i.e., retroactively terminate) coverage if such coverage was

gained due to an individual (or person seeking coverage on behalf of an individual) performing an act, practice or omission that constitutes fraud or making an intentional

misrepresentation of material fact. I understand that any person who applies for coverage or ﬁles a claim containing any materially false information may be subject to

disciplinary action, up to and including termination of beneﬁts and/or employment. I understand that my elections may not be changed or voluntarily cancelled at any

time during the plan year (ending December 31) unless a qualifying status change occurs, as deﬁned by the applicable plan, and the Ofﬁce of Human Resources receives

timely notiﬁcation of such change as provided under the applicable plan. I authorize the university to deduct from my pay, on a pre-tax or after tax basis, as the case may

be, the applicable employee contributions described in the beneﬁt plan rates online at hr.osu.edu/beneﬁts/rates. I understand that this authorization to deduct employee

contributions directly from my pay (i.e., a salary redirection arrangement) will remain in effect during the period of coverage and is not revocable, except as described in

the applicable plan. I understand and agree that in the event my university pay is not sufﬁcient to pay the employee contributions for the beneﬁts that I elect, or if I go on an

unpaid leave of absence, I will be billed directly for these employee contributions. In such case, I agree to pay those employee contributions promptly and in full. I understand

that, if employee contributions are not paid in full, the beneﬁts will be terminated for lack of payment and I will be responsible for employee contributions missed prior to my

coverage termination date. I certify that all information provided on this form is true and correct to the best of my knowledge.

Signature Date

Ofce of Human Resources, rev. 08/2023

____________________________________________________________________

_____________________________________________________________________________________________________________________________________

Employee Name Employee ID#

SECTION 4 -B: EMPLOYEE AND ELIGIBLE DEPENDENT ENROLLMENT INFORMATION

Please list additional family members to whom new coverage or coverage changes will apply.

Name

Relationship

to Employee

(use codes

on reverse)

Birth Date Gender

Address different

from employee?

Social Security Number

(required)

Choose coverage for

each eligible dependent

Medical Dental Vision

M/D/Y AGE M F YES NO YES NO YES NO YES NO

If dependent’s address differs from employee’s address, provide dependent’s address in SECTION 6.

Please use the following numbers and letters to indicate Relationship to Employee. Review dependent eligibility guidelines online at

hr.osu.edu/beneﬁts/dependent-eligibility-guidelines.

0 Employee

2 Dependent Child (under age 26, unless fully disabled).

1 Spouse

Please specify:

2A Dependent Child of Employee

2B Dependent Child of Employee’s Spouse

After you have enrolled your eligible dependents, a dependent veriﬁcation packet will be mailed to your home address. All health plan members

must provide proof of each covered dependent’s eligibility. Failure to provide sufﬁcient proof will result in coverage termination for the dependent(s)

not veriﬁed.

SECTION 6: DEPENDENT ADDRESS INFORMATION (IF DIFFERENT FROM EMPLOYEE’S ADDRESS)

If you indicated in SECTION 4-A or 4-B that any dependent’s address differs from the employee’s address, please provide that dependent’s

name and mailing address below

Dependent’s Name

Street Address

City State Zip

Dependent’s Name

Street Address

City State Zip

If you have questions, contact the Ofﬁce of Human Resources HR Connection:

Email: hrconnection@osu.edu • hrconnection.osu.edu

Retain a copy of this form for your records. Submission options for the signed original of this form:

• Upload to the secure hrconnection.osu.edu portal by selecting “Submit a Form” (recommended)

• Mail to Ofﬁce of Human Resources, 1590 N. High St., Suite 300, Columbus, OH 43201-2190

• Fax to (614)292-7813

• Mail to hrconnection@osu.edu with subject line “Health Election Form”

Ofce of Human Resources, rev. 08/2023

• Phone: 614-247-myHR (6947) or 800-678-6010