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| GBP Supplemental Information
Form (Faculty, Staff and Graduate Students) |
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In this step, you will complete the Group
Benefits Program (GBP) Supplemental Insurance Form. |
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If you choose not to enroll yourself and your dependents in the health coverage, you do not need to complete this Form. |
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The Step 3 involves completing the Group
Benefits Program (GBP) Supplemental Insurance Form. The Form is for selecting a primary care physician and providing other insurance information to your health plan. It is NOT an enrollment form and does NOT verify eligibility. Go to Step 2-a for Enrollment Form. |
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When you enroll in a health plan, you must select a Primary Care Physician (PCP) for yourself and your dependents. Each health plan requires you to use PCPs to direct your health care, except for the non-network and out-of-area options available in HealthSelect. Your PCP provides you with referrals to network providers, such as specialists, hospitals, and other licensed providers for health care services. In the case of FirstCare (HMO), no coverage is offered for services - other than emergency care, OB/GYN services, or routine eye exams - when not coordinated through your PCP. For additional information for Choosing a Primary Care Physician see below under 'Section D,' under your Health Plan. |
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The Form is divided into five sections, namely - Section A, B, C, D, and E. Please submit the completed, signed & dated Form along with the rest of your Forms and Documents to the
HRS - Employee Service Center in Drane Hall in Room 135. You can complete the Form online and then print it on your printer. A Form completed online is more legible and easy to understand. |
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There is a limited 31-day enrollment period for insurance. |
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Download the GBP Supplemental Information Form. Click on the link and save the file to the hard disk on your computer. Open the downloaded Form and complete it by typing-in the fields. Keep saving regularly. Turn in the completed Form to the benefits department by printing it (after completion). |
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| Section A - Employee Data |
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 | Complete this section with your personal data, specifying your Social Security Number, Name, Mailing Address, City, State, Zip and Telephone Numbers. The 'Eligibility County,' would be the county where you live. The DeptID is 0733, which is already filled-in. |
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| Section B - Other Insurance Data |
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| Skip this Section. |
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| Section C - Medical Coverage Information |
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| Skip this Section. |
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| Section D - Primary Care Physician Selection |
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Before completing this section you will have to choose your PCP. | | |  | For choosing your PCP if you have picked HealthSelect - click here. | | For choosing your PCP if you have picked FirstCare - click here. | | | | Do not include HealthSelect out-of-area participants in this Section, use 'Section E' for them. | | | | Write the Name of your chosen health plan. | | Write Patient's Name, SSN, Gender, Birthdate & PCP Name for yourself and each covered dependent, even if you are selecting the same physician for all covered persons. | | PCP No. - Write the PCP No. in this column for each covered person. You can leave this blank, if you can not get the number. | | Existing Patient - Write 'Yes,' if the patient is already with the PCP or 'No,' if not. | | OB/GYN - If you have chosen 'HealthSelect' as your health carrier then you can skip this column. If you have chosen 'FirstCare' then it is required for female participants to designate an OB/GYN prior to accessing health care services. |
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| Section E- Other Dependent Information |
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| Complete this section if you are enrolling in HealthSelect (In-Area) and your eligible dependent lives out-of-area or in another HealthSelect network area. | | Complete this section if you are enrolling in FirstCare (HMO) and your eligible dependent lives in another Texas service area of FirstCare. |
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Sign, date and return this form along with other forms to the address mentioned in Step 5. |
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