NHADA Employee Application and Adjustment Form
This form is used by groups offering Dental, Life, Short-term Disability, and/or Vision Insurance.
The Notice of Termination of Coverage form is your official notification of a potential COBRA qualifying event; therefore, it is important that you submit this form as soon as possible. We suggest submittal within 48 hours of the event. The Notice of Termination of Coverage form must be received by NHADA prior to the effective date. Coverage will end on the last day of the month in which the Notice of Termination form was received.
Note: This form should not be used for voluntary cancellation of coverage, if an employee remains employed. Harvard Pilgrim enrollment forms can be used for this purpose; for other products, use the NHADA Employee Application and Adjustment form.
Harvard Pilgrim Health Care Forms
To claim reimbursement for an approved health club or fitness facility membership that you have paid for out-of-pocket.
To claim reimbursement for medical and hospital services covered under your plan that you have paid for out-of-pocket.
For HMO, POS and PPO Plans, to claim reimbursement for prescription medications covered under your plan that you have paid for out-of-pocket.
To claim reimbursement for covered dental care received outside the dental network.
To claim reimbursement for prescription eyeglasses and frames or prescription contact lenses covered under your plan that you have paid for out-of-pocket.
To claim reimbursement for covered Behavioral Health services received out-of-network.
To claim reimbursement for medical and hospital services received outside the U.S. that are covered under your plan.
To authorize Harvard Pilgrim to release/disclose certain health information according to the terms you specify.
To allow behavioral health practitioners involved in your care to release health information to other health providers according to the terms you specify.
To authorize an individual to discuss and make decisions related to your health care and coverage.
To verify your dependent's eligibility as a disabled adult; includes Authorization to Obtain Protected Health Information.
To allow Harvard Pilgrim representatives to,speak to a parent about the health coverage and care of their dependent (under age 18) when the parent is not listed on that minor's policy. Must be notarized.
VSP Vision Care Forms
Life Insurance Forms
This form is used when an employee's beneficiary(ies) seek entitlement following the employee's death or dismemberment.
Complete form must be signed and mailed to: NHAD Services, Inc. - Insurance Division
This form must be completed and submitted with the employee's application when electing Life or Short-term Disability insurances if election of coverage was previously refused. For groups electing Short-term Disability, with fewer than six enrollees, Evidence of Insurability is always required. For groups electing Short-term Disability, with six or more enrollees, Evidence of Insurability is only required for the portion of the weekly benefit amount in excess of $500. Forms should be returned to:
NHAD Services, Inc. - Insurance Division
Short-Term Disability Forms
Short-term Disability Claim Form
This form is used when an employee, enrolled with Short-term Disability, is out of work for a qualified illness or injury. Please note that Part B must be completed by the attending physician. Return completed form to NHAD Services, Inc.- Insurance Division.
Short-term Disability Notice of Return to Work
This form is to be used when an employee returns to work following a short-term disability claim.
This form should be completed and returned to: NHAD Services, Inc. - Insurance Division
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