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NHIP Registration Form

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magnoliazane
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178 views2 pages

NHIP Registration Form

Uploaded by

magnoliazane
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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NHIB EMPLOYER/EMPLOYEE ENROLLMENT FORM

Employer ID: __________________________________

Employer Name: _______________________________


PLEASE USE BLOCK CAPITALS WHEN COMPLETING THIS FORM

Member Name: Employment Date:


DOB (mm/dd/yyyy): Marital Status: Single Married Divorced Widowed
Gender: Male Female Occupation:
Country of Birth: NHIP #:
Home Address:
Area:
Island: Country:
Phone: Other Phone:
E-Mail Address:
Private Insurance: Yes No Insurer:

TCI Status Card #: Date From;


NIB#: Date From:
Passport # / Country: Date From/Thru:
Driver’s License # / Country: Date From/Thru:
*Work Permit #: Date From/Thru:

Declaration by Employer: I, _____________________________________ (full name of employer) declare that the


particulars provided by the applicant in this enrollment form is true and correct to the best of my knowledge.

Signed by: ______________________________ Date (mm/dd/yyyy): ___________________________

Declaration by Employee: I, _____________________________________ (full name of applicant) hereby declare that the
information I have provided in this application is true to the best of my knowledge and belief and I make it knowing that if I
have made any false or misleading statements I am liable to be prosecuted under the National Health Insurance Ordinance.

Signed by: _______________________________ Date (mm/dd/yyyy): ___________________________

CONSENT TO RECEIVE AND RELEASE MEDICAL INFORMATION

I, _____________________________________ (full name of applicant), hereby give permission to the National Health
Insurance Board to receive and release medical records or other information about my medical records to individuals who
will be involved in the delivery of medical treatment to me. The authorization is indefinite while I am enrolled in the
National Health Insurance Plan, unless I inform the National Health Insurance Board that I no longer authorize the
disclosure of information.

Print Name: ________________________________________ Signature: ________________________________

Date (mm/dd/yyyy): _________________________________

FOR OFFICIAL USE:

RECEIVED BY: _____________________________________ DATE: __________________________

12/16
Declaration by Employee: I, ___________________________________
hereby declare that I understand the limitations as it pertains to my
benefit coverage.

In accordance with the Benefit (Amendment) Regulations 2016; the


following applies:

Regulation 5A
(2) The Plan will cover medical services in the Islands only, for the first
six months of registration with the Plan, for a beneficiary who holds a
work permit and his dependents.
(3) After the first six months mentioned in subregulation (2), such
beneficiary and his dependents shall be entitled to receive medical
services outside the Islands as follows—
(a) if he has made contributions to the Plan for 6 months to 2 years,
maximum coverage of $200,000;
(b) if he has made contributions to the Plan for 2 years to 4 years,
maximum coverage of $400,000;
(c) if he has made contributions to the Plan for 4 years to 6 years,
maximum coverage of $600,000;
(d) if he has made contributions to the Plan for 6 years to 8 years,
maximum coverage of $800,000;
(e) if he has made contributions to the Plan for 8 years to 10 years,
maximum coverage of $1 million dollars;
(f) if he has made contributions to the Plan for greater than 10 years,
unlimited coverage.

Signed by: ____________________________

Date (mm/dd/yyyy): ___________________________

12/16

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