Get the free CY17 Active Enrollment Form Print - University of Maryland School ...

The Mandatory Insurer Reporting Law 42 U.S.C. 1395y b 7 requires group health plans to report SSNs in order for Medicare to coordinate payments with other insurance benefits. Reminder This is not a yearly deduction amount. THIS IS THE AMOUNT DEDUCTED PER PAY PERIOD FOR JANUARY 2017-DECEMBER 2017. Separate selections are required. Prescription Drug Coverage Dental Coverage CHOOSE ONE DENTAL PLAN United Concordia DPPO Delta Dental DHMO For the DHMO Plan You must select a primary Dentist office...

How to fill out cy17 active enrollment form

How to fill out cy17 active enrollment form

1. Read the instructions on the CY17 Active Enrollment form carefully.
2. Start by entering your personal information, such as your name, date of birth, and contact details.
3. Provide information about your current health insurance coverage, including the insurance company name, policy number, and effective dates.
4. Indicate whether you want to make any changes to your coverage or if you want to continue with the same plan.
5. If you want to make changes, specify the type of changes you want to make, such as adding or removing dependents or changing your coverage level.
6. Review the available plan options and select the one that best suits your needs.
7. If you have any specific health conditions or medications, make sure to provide that information as requested.
8. Carefully review all the information you have provided for accuracy before submitting the form.
9. Sign and date the form to validate your enrollment.
10. Submit the completed form to the designated authority or follow the submission instructions provided.

Who needs cy17 active enrollment form?

1. Anyone who is currently enrolled in a health insurance plan and wishes to make changes or continue with the same coverage for CY17.
2. Individuals who have experienced changes in their personal circumstances, such as getting married, having a child, or moving to a new location.
3. Employees who have a benefits package that includes health insurance and need to review and update their coverage for the upcoming year.
4. Individuals who were not previously enrolled but now want to avail health insurance coverage for CY17.
5. Anyone who wants to explore different plan options and compare them with their current coverage.

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What is cy17 active enrollment form?

Cy17 active enrollment form is a form used to enroll in a specific program or service during the calendar year 2017.

Who is required to file cy17 active enrollment form?

Individuals who wish to enroll or make changes to their enrollment in a specific program or service during the calendar year 2017 are required to file cy17 active enrollment form.

How to fill out cy17 active enrollment form?

To fill out cy17 active enrollment form, individuals must provide accurate and up-to-date information about their enrollment preferences and any changes they wish to make.

What is the purpose of cy17 active enrollment form?

The purpose of cy17 active enrollment form is to collect information from individuals in order to process their enrollment in a specific program or service during the calendar year 2017.

What information must be reported on cy17 active enrollment form?

Information such as personal details, enrollment preferences, and any changes to enrollment status must be reported on cy17 active enrollment form.