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San Joaquin Health Care 2004 JPA Handbook

Enrollment Process
Enrollment Form
To enroll you and your dependents, make sure that the Enrollment and Change Form- provided to you by your personnel department – is completed and turned in to your Personnel Department prior to the end of the open enrollment period (September 5th, 2004). If you are an R.S.E.M.P. retiree you must return your enrollment form to Legacy Enterprises.
To assist you in selecting the appropriate medical coverage for you and your family, please refer to the Medical Plan Selection Worksheet on the next page.
Make sure that you have added dependent coverage as appropriate and legibly complete the enrollment form in its entirety. If your dependents are not listed in the appropriate sections, they will not be enrolled for coverage. If you choose a PPO Plan, you must complete the Blue Cross form in addition to the universal form.

Need Assistance with Enrollment
If you have any questions or need assistance, please call your school’s Personnel Department or Legacy Enterprises Insurance Services, Inc.

Medical Plan Selection Worksheet
This benefit handbook provides a worksheet on the following page to assist you in selecting the most appropriate medical plan for you and your family. After reviewing the information on the medical plan options in Section Five of this booklet, place your top three selections in the first row of the table. Then proceed down the list answering each question. Once you have completed the table, you will be able to identify the medical plan that best meets your family’s needs.

Medical Plan Worksheet
Health Plan Name
1st Choice
2nd Choice
3rd Choice
Do I need to choose a PCP?   
Is my Current Physician a participating provider of the Plan?   
Do I need a referral to a specialist?   
Are specialist referrals limited to the same medical group or IPA?   
My annual out-of-pocket expenses are:   
My annual deductible is:   
My monthly premium contribution is:   
Do I have to file a claim form?   
My cost for an office visit is:   
My cost for a 30-day prescription is:   
My cost for a 90-day (mail order) prescription is:   
How many chiropractic visits are covered?   
Does the Plan cover over-the-counter medications?   


©2006 Legacy Consulting Insurance Services, Inc.
811 W Fremont Street
SUITE B
Stockton, CA 95203
Phone: (209) 546-0402 ~ Fax: (209)546-0824
San Joaquin JPA Handbook 2004