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Affidavit of Dependent for Tax purposes -
This form must be completed when a Participant is enrolling their same-sex domestic partner to the Plan and is claiming their same-sex Domestic Partner as Dependent for “TAX” purposes. This form must be signed
by both the Participant and the Domestic Partner and it must be notarized. This form is in addition to the Affidavit of Domestic Partnership form.
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Affidavit of Domestic Partnership -
This form is required for all Participants enrolling their same-sex domestic partners to the Plan. This form must be signed by both the Participant and the Domestic partner and it must be notarized.
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COBRA self-pay rates
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Medical/Dental Plan selection option -
You only need to complete this form if:
- You are initially or newly eligible or;
- You wish to change the medical/hospital and/or the dental plan in which you are currently enrolled. (please be aware enrollment in the HMO plans for both Medical/Hospital and Dental, is only during July)
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Requirements for Adding Dependents to your Health Insurance, and Application for Coverage-Non-Biological Dependent Child
- This is the chart that spells out what documents are required in order to add your dependent(s) to your health insurance. Also included is the form required for adding a non-biological child to your health insurance.
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Change of Address - This is Important.
To ensure that you receive correspondence sent from the Plan, it is important that you notify the Eligibility
Department immediately of any change in your mailing address.
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Audit & Collections Department Participant Service Form - Participants
complete this form if they believe there are errors in the Plans' record of their work history. Please note that sufficient supporting documentation is needed in order to initiate an investigation. Once you have gathered
the necessary information/documentation, please send copies via US Postal Service to the attention of the Audit & Collections Department.
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Coordination of Benefits-Spouse's Requirements Under the Blue Shield Plan-Instructions - Please read this 2-page letter to determine which forms to complete. |
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Coordination of Benefits "Form 1" Questionnaire - Participants must complete and submit this "Form 1" in order to establish health eligibility for their
spouse or same-sex domestic partner with the MPI Health Plan. |
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Coordination of Benefits "Form 2" Questionnaire - The spouse's/same-sex domestic partner's employer completes this "Form 2" certifying to their health insurance status. |
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Coordination of Benefits "Form 3" Declaration - Participants' spouses or same-sex domestic partners who are retired, unemployed, self-employed, or freelance and have no group
health plan may remain covered by the MPIHP, but must fully complete, sign and submit this Coordination of Benefits Declaration and "Form 1" above. |
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Coordination of Benefits "Form 4" Confirmation - Participant's spouse/same-sex domestic partner must complete this confirmation of employer group health plan enrollment.
Also indicates coverage provided for children under employer group health plan.
If you previously notified the MPI Health Plan of possible future enrollment in your employer's group health plan, this form must be completed and returned to the MPIHP Office upon actual
enrollment in that plan.
If the MPI Health Plan determines that the spouse was eligible for health benefits through their employer but did not enroll, the MPI Health Plan will not provide any coverage for the spouse. |
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Health Plan Beneficiary Card - Upon qualification for Initial Eligibility,
you must complete a Beneficiary/Enrollment card to enroll your Eligible dependents (children, spouse, same-sex domestic partners, etc) and designate the beneficiary(ies) of your life insurance.
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