ENROLLMENT INFORMATION

The following information is provided to explain the process of enrolling and terminating employees and/or dependents. In order to ensure timely enrollment of new eligible employee, please complete and return the membership report and group employee application.

Attachment #1: Step-By-Step Guide

This guide was created to assist with the completion of enrollment application/change form. The text denoted in red provides additional information to help understand what information is being requested.

Attachment #2: Enrollment Application

All new employees and those employees requesting a change in their coverage, must complete this entire form, unless otherwise instructed, to prevent delays.

Any questions you have as you complete this form may be directed to Customer Service.

Once completed, these forms may be mailed to: AultCare Eligibility Department PO Box 6910 Canton, OH 44706

It may also be faxed directly to our eligibility Department at 330-363-7746. All changes must be received by the 10th of the month to be reflected on your next bill.

Attachment #3: Cancellation and Continuation Form

Please indicate all cancellations on this report. Do not make changes on the monthly premium statement. Utilize transaction codes for each change. Include enrollment form where indicated and provide within 31 days of event. (Signed enrollment forms must include spouse's signature when applicable.

Attachment #4: HIPAA Disclosure Form Notice of Privacy Practice Member Guide Letter

The attached enclosures must be given to any potential AultCare enrollee in addition to the Group Employee Application so that the person understands portability and creditable coverage.

Attachment #5: Getting the Most from your Healthcare plan