295 Lafayette St.

6th Floor | NY, NY 10012

Individual Enrollment Application/Change Form (Off Exchange)
Bronze
Select if youre covering a dependent aged 26 - 29
Add Dependent Update Name and/or Address Chane Fene| P|an
Bronze Edge+ Silver Edge Individual
Single Married Dones||c Par|ner
Gold
Male Female
Individual & Spouse
Bronze Edge
Remove Dependent Leaving Oscar Marital Status Change
Silver Silver Edge+ Paren| & Ch||d,ren) Gold Edge Family
Choose
your plan
Make changes to
your current plan
Who are you buying
insurance for?
Last Name First Name Da|e o F|r|h ,MM/DD/````)
City
City
State County
State County
Zip Code
Zip Code
Social Security No. Gender MI
Apt #
Apt #
Home Address
Telephone:
Name Address
Cscar Menber D ,| na||n chane |o p|an)
Email Address
Marital Status:
______/______/___________
_____/_____/_________
Hone , )
Ce|| , )
Mailing address, if different from home address
Effective Date of Coverage:
List Eligible Family Members Below
,F|rs| nane, M|dd|e n|||a|, Las| nane)
01 2014
GA / Broker Information (if applicable)
*Please call us at 1-855-OSCAR-55 to request a disabled dependent form
Gender
,M/F)
Social Security No.
Disabled Dependent
,over ae 2o*)
Date of Birth
,MM/DD/````)
Pr|or Carr|er
Name
Group
Number
Member ID Fec||ve Da|es
From:
From:
From:
From:
From:
From:
From:
From:
To:
To:
To:
To:
To:
To:
To:
To:
Spouse
Applicant
GA Name GA License Number GA Agency Name Phone Email
Fro|ers Nane Fro|er L|cense Ndnber Fro|ers /ency Nane Phone Email
CoFro|ers Nane CoFro|ers L|cense Ndnber CoFro|ers /ency Nane Phone Email
Child
Dependent
If you or any of your eligible family members currently have health insurance
or have had it in the past 12 months, please provide the following:
Please Read the Following Carefully
I understand that upon review of my Contract that I may cancel it. Any request to cancel must be made in writing within 10 days from the date I receive the Contract. On behalf of myself and any covered dependents,
to the extent permitted by law, I hereby authorize all health care providers who have rendered service to any of us and any payers of claims to provide to Oscar any records pertaining to care provided, claims
pa|d and/or odr ned|ca| h|s|ory ad|hor|.e Cscar |o prov|de sdch |norna||on |o ne|wor| phys|c|ans or |he pdrpose o con||nd||y o care, ned|ca| nanaenen|, e|c /ny person who |now|n|y and w||h |n|en| |o
deradd any |nsdrance conpany or o|her person |es an app||ca||on or |nsdrance or s|a|enen| o c|a|n con|a|n|n any na|er|a||y a|se |norna||on, or concea|s or |he pdrpose o n|s|ead|n, |norna||on concern|n
any ac| na|er|a| |here|o, conn||s a raddd|en| |nsdrance ac|, wh|ch |s a cr|ne, and sha|| a|so be sdbec| |o a c|v|| pena||y no| |o exceed ve |hodsand do||ars and |he s|a|ed va|de o |he c|a|n or each sdch
v|o|a||on an app|y|n or coverae or nyse|, ny spodse and ny e|||b|e dependen| ch||dren naned on |h|s app||ca||on /|| s|a|enen|s nade w||h|n |h|s orn are |rde and accdra|e |o |he bes| o ny |now|ede
Signature Date
Return to:
______/______/___________
Da|e o Fven| ,dependen| / nar||a| s|a|ds chane) P|ease see |he bac| o |h|s orn or |ns|rdc||ons on how |o na|e a chane
05-19-1977
WESTCHESTER
Robert S. Hurley
NY
jdavis10470@gmail.com

eHealthInsurance Services, Inc.

992-7307
5
917
Davis
10550 12B

bronx
109-60-9892
243 West 1st Street
James
03-27-2014
917

LA-1145132
992-7307
116eed34e21 James Davis
James Davis (esign)
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ns|rdc||ons or na||n chanes |o yodr con|rac|
1.Write the current contract holders information at the top of the form
(name, address, date of birth, gender, SSN, phone, and email).
Exception: if you are making a change to the contract holders name or address,
please write the new name or address (see below for further instructions).
2.Enter current Oscar member ID in the middle of the form.
3.Follow the instructions below for the specic change you want to make.
4.Enter the month you want the change to take eect in the Eective Date of Coverage eld.
Adding a dependent
Check the Add Dependent box.
Indicate the date of qualifying event:
Date of birth or adoption (Congrats!).
Date other health insurance coverage was lost
Enter the new dependents information in the eligible family members section.
Removing a dependent
Check the Remove Dependent box.
Enter the information of the dependent being removed in the eligible family members section.
Updating name and/or address
Check the Update Name andlor Address box.
If changing the contract holders name andlor address:
Enter the new nameladdress in the appropriate elds at the top of the form. Please include all other
identifying information as well (date of birth, SSN, telephone number, email address).
If changing the name of a dependent: Enter the new name of the dependent in the appropriate eld under
the eligible family members section. Please include the other identifying information as well (gender, SSN,
and date of birth).
Leaving Oscar
If you really must go, check the Leaving Oscar box. Well miss you!
Enter the contract holders information in the appropriate elds at the top of the form.
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Check the Change Benet Plan box.
Enter the contract holders information in the appropriate elds at the top of the form.
In the choose your plan section at the top, indicate the plan youd like to switch into.
Please be aware that if your contract is an Individual & Spouse, Parent & Child(ren), or Family,
the change will be applied to everyone on the contract.
Marital status change
Check the Marital Status Change box.
Indicate the date on which your marital status changed.
If youre including a new family member (spouse or domestic partner), check the Add Dependent box
and enter the new family members information in the eligible family members section.
If youre removing an existing family member, check the Remove Dependent box and enter the
information of the person being removed in the eligible family members section.
A new kind of health insurance.
116eed34e21 James Davis
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