Epstein Secrets

u intend to join one? o Yes c No Primary Care Physician' Physician First & Last Name Address Existing Patient? o Yes o No Primary Care Dentist' Dentist First & Last Name ID# ID# — Existing Patient? r Yes III No B. Waiver of Coverage Declining Spouse's Covered COBRA Tri-Care .__ I (vie) o Other coverage d

dependents are enrolling. If your employer offers a choice of plans. indicate which plan you are selecting. Indicate the dollar amount selected for the Life and Accidental Death & Dismemberment (.=). Supplemental Life, Short-Term Disability (STD), and Long-Term Disability (LTD) plans. Benefit offerings are dependent upon employer selection.

gin currently participating one? Yes No Primary Care Physician' Existing Patient? Yes Physician Firs & Last Name No Primary Care Dentist' Dentist First & Last Name Existing Patient? Yes No Address IDS IDS Relationshipi Last Name First Name MI Sex o M 0 F Date of Birth / / Dependent Social Securi

r your dependents are enrolling. If your employer offers a choice of plans, indicate which plan selecting. Indicate the dollar amount selected for the Life and Accidental Death & Dismemberment ( . Supplemental Life. Short-Term Disability (STD), and Long-Term Disability (LTD) plans. Benefit offerings r ependent upon employer selection. Pe

do you intend to pin one? : ) Yes o No Primary Care Physician' Existing Patient? E Yes Physician First .6 Last Name 2 No Primary Care Dentist' Dentist First & Last Name Existing Patient? o Yes L: No IDS Address IDS — Relationship' Last Name First Name MI Sex - : M F Date of Birth / / Dependent Social

ch you or your dependents are enrolling. ll your employer offers a choice of plans, indicate which plan you are selecting Indicate the selected for the Life and Accidental Death & Dismemberment (A08.0). Supplemental lie. Short (STD). and Long-Tenn Disabihly (LTD) plans. Benefit offerings are dependent upon employer A/ /A - dollar amount -T