ࡱ> #` .bjbj\.\. x>D>D$C|   $DLLLPLxMlDwN R@LRLRLRTxXYwwwwwww$lyh{Z9w `fTfT@``9wLRLRNwbbb`LRRLRwb`wbbph"qLRN P{ L`pWrdw0wq.|"af.| q.| qZ[bD\\6ZZZ9w9wbvZZZw````DDD$(*d"DDD(*DDD  BULLETIN NO. 07-17 TO: ALL NEW JERSEY HEALTH INSURANCE COMPANIES; HOSPITAL SERVICE CORPORATIONS; MEDICAL SERVICE CORPORATIONS; HEALTH SERVICE CORPORATIONS; HEALTH MAINTENANCE ORGANIZATIONS; DENTAL SERVICE CORPORATIONS; DENTAL PLAN ORGANIZATIONS; PREPAID PRESCRIPTION SERVICE ORGANIZATIONS; ORGANIZED DELIVERY SYSTEMS; AND OTHER INTERESTED PARTIES FROM: STEVEN M. GOLDMAN, COMMISSIONER RE: AMENDMENTS TO THE HINT FORMS On March 26, 2007 the Department issued Bulletin No. 07-07, which addressed amendments to the HINT Enrollment Forms, Exhibits 1A and 1B of the Appendix to N.J.A.C. 11:22-3 (Electronic Transmission and Receipt of Health Care Claims - HINT Enrollment forms). It has come to the Departments attention that the forms in Exhibits 1A and 1B as attached to Bulletin 07-07 do not include the LOC #s under the Activity section for the Primary, OB/GYN or Dentist entries. Therefore the Department is providing as attachments hereto the corrected form pages that now include spaces for the entry of the LOC # information. These forms can be accessed via the Departments website at: http://www.state.nj.us/dobi/bulletin.shtml. The Department intends to propose amendments to Exhibits 1A and 1B of N.J.A.C. 11:22-3 to codify the revised forms in the near future. 8/29/07 /s/ Steven M. Goldman Date Steven M. Goldman Commissioner DHT07-06/inoord B. [Employee] Information to be completed by the [Employee] Name (Last, First, MI): SSN:Home Street/Apt:________________________________________________________________________________________ Street/Apt:________________________________________________________________________________________ City:___________________________________________________ State:_____ Zip Code: _____________________ Birthdate (mm/dd/yyyy):  FORMCHECKBOX  Male  FORMCHECKBOX  FemalePhone: (_____)________________ [Email: _______________________________]Work [Employer] Name:__________________________________________________________________________________ Address:__________________________________________________________________________________________ City:___________________________________________________ State:_____ Zip Code: ______________________ Phone: (_____)__________________ [Email: _________________________________] Employment Date: _____/_____/_____ Hours worked per week:_________Activity FORMCHECKBOX  Add  FORMCHECKBOX  Remove  FORMCHECKBOX  Continuation  FORMCHECKBOX  Other Change If a name change, indicate prior name:[Primary LOC #:] _______________________________________________________ address: zip+4 ][NPI #:][Current Patient:  FORMCHECKBOX  Yes  FORMCHECKBOX  No][Ob/Gyn LOC #:] _______________________________________________________ address: zip+4 ][NPI #:][Current Patient:  FORMCHECKBOX  Yes  FORMCHECKBOX  No] [Dentist LOC #:] _______________________________________________________ address: zip+4 ][NPI #:][Current Patient:  FORMCHECKBOX  Yes  FORMCHECKBOX  No]Other Health Coverage?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes: Payer Name: ____________________________________________________________ Policy #: ________________________________________ Medicare ID#, if any: [Other Rx Coverage?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes: Payer Name: ____________________________________________________________ Policy #: ___________________________________________ Medicare ID#, if any: ]Previous Coverage?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If Yes: Effective date: _____/_____/_____ Termination date: _____/_____/_____Payer Name:____________________________________________________________ Policy #:____________________________ [Submit a Certificate of Creditable Coverage]C. Plan Option to be completed by the [Employee] Check one [Plan Name] [and] [Copay] [and] [or] [Deductible] [and] [or] [Coverage Status]D. Other Individuals Covered to be completed by the [Employee] Identify individuals other than yourself for whom you are adding/changing/removing/continuing coverage. Attach additional pages if necessary, with your signature and dated. [Attach proof if full-time post-secondary student.] [Attach proof of disability.] 1. Spouse; Domestic or Civil Union Partner2.Child3. Child4. Child FORMCHECKBOX Add  FORMCHECKBOX  Remove  FORMCHECKBOX Other  FORMCHECKBOX Continue Spouse  FORMCHECKBOX Continue CU Partner (NJSGC) FORMCHECKBOX  Add  FORMCHECKBOX  Remove  FORMCHECKBOX  Other  FORMCHECKBOX  Continue  FORMCHECKBOX  Add  FORMCHECKBOX  Remove  FORMCHECKBOX Other  FORMCHECKBOX  Continue FORMCHECKBOX  Add  FORMCHECKBOX  Remove  FORMCHECKBOX Other  FORMCHECKBOX  Continue NONGROUP ENROLLMENT/CHANGE REQUEST [Carrier Logo] [Carrier Name] A. Type of Activity to be completed by [Applicant] Refer to instructions [on back] before completing this form. Print clearly. Activity Check all that applyEffective Date/ Date of EventReasonADD FORMCHECKBOX  Enrollment of a new [Insured/Enrollee/Subscriber]  FORMCHECKBOX  Add Spouse[/Civil Union Partner] [ FORMCHECKBOX  Add Civil Union Partner]  FORMCHECKBOX  Add Domestic Partner  FORMCHECKBOX  Add Dependent Child_____/_____/_____ _____/_____/_____ [_____/_____/_____] _____/_____/_____ _____/_____/_____________________________________________________________ ________________________________________________________ [_______________________________________________________] ________________________________________________________ ________________________________________________________ REMOVE FORMCHECKBOX  Remove [Insured/Enrollee/Subscriber]  FORMCHECKBOX  Remove Spouse[/Civil Union Partner] [ FORMCHECKBOX  Remove Civil Union Partner]  FORMCHECKBOX  Remove Domestic Partner  FORMCHECKBOX  Remove Dependent Child_____/_____/_____ _____/_____/_____ [_____/_____/____] _____/_____/_____ _____/_____/_____________________________________________________________ ________________________________________________________ [_______________________________________________________] ________________________________________________________ ________________________________________________________ OTHER CHANGE FORMCHECKBOX  Name Change  FORMCHECKBOX  Change Plan  FORMCHECKBOX  Other  FORMCHECKBOX  [Add/Change Office ID Numbers: Primary/OB/Gyn] _____/_____/_____ _____/_____/_____ _____/_____/_____ _____/_____/_____ _______________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________B. [Applicant] Information Name (Last, First, MI): SSN:Birthdate (mm/dd/yyyy) FORMCHECKBOX  Male  FORMCHECKBOX  Female[Email:]Are you a resident of ӣƵ?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoDo you maintain a home in any other state?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes: Name of State:______________________________ Number of months you live there each year: _________Address InformationPrimary Residence: Street/Apt:___________________________________________________________ Street/Apt:___________________________________________________________ City:___________________________________________________ State:______ Zip Code: _____________________ Phone: (_____)_________________Other Residence: Street/Apt:___________________________________________________________ Street/Apt:___________________________________________________________ City:___________________________________________________ State:______ Zip Code: _____________________ Phone: (_____)_________________Your billing address:  FORMCHECKBOX  Primary residence  FORMCHECKBOX  Other residence  FORMCHECKBOX  P.O. Box or Other (specify):Activity FORMCHECKBOX  Add  FORMCHECKBOX  Remove  FORMCHECKBOX  Other Change  FORMCHECKBOX  Continue If a name change, indicate prior name:[Primary LOC#:] ______________________________________________________ address: zip+4 ][NPI #:][Current Patient:  FORMCHECKBOX  Yes  FORMCHECKBOX  No][Ob/Gyn LOC#:) _____________________________________________________ address:] zip+4 [NPI #:][Current Patient:  FORMCHECKBOX  Yes  FORMCHECKBOX  No]      PAGE  PAGE 1   PAGE  PAGE 2 ӣƵDepartment of Banking and Insurance Legislative and Regulatory AffairsJon S. CorzinePO Box 325 Trenton, NJ 08625-0325Steven M. GoldmanGovernorTel (609) 984-3602 Fax (609) 292-0896Commissioner Visit us on the Web at www.njdobi.org ӣƵ is an Equal Opportunity Employer Printed on Recycled Paper and Recyclable 1DEFe_ ` f m p   6 7 ? C N V X Y ^ _ g h i j p q u v } ~    0 ^ ׸۸hTdS hw'hw'h@hr <hehhuh1ILhy,h%hE h5 hE5h^ hE5 h%h%H_ `     : Q _ o p q  gd1IL$ H^`Ha$gd%$H^`Ha$gd%$a$gdE$a$gdE,-.      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