+ MEDICAL/DENTAL/VISION COVERAGE ENROLLMENT FORM
E-mail: applications@mediexcel.com     Telephone: (619) 421-1659     www.mediexcel.com
***HR, PLEASE FILL IN SHADED AREA OF APPLICATION BELOW***
New Hire Add Dependent Personal Information Update
Group Number: Effective Date:
EMPLOYEE INFORMATION
Last Name
First Name
Birthday (MM/DD/YYYY)
Street Address
City
State
Zip Code
Country
Sex
Male Female
Social Security #
Telephone Number
Emergency Telephone Number
PLEASE PROVIDE E-MAIL:
Marriage Status
Single Married
Domestic Partnership
Select Your Plans
Medical: MEP Medical: QEP
Dental: D200
Vision
Prefered Language
Spanish
English
Prefered Region
Tijuana
Mexicali
IF YOU ARE ENROLLING DEPENDENTS, PLEASE COMPLETE THIS SECTION
Last name First Name Birthday Sex M/F Social Security # Select Your Plans
Spouse/Domestic Partner



M F

Medical Dental Vision
Dependent



M F

Medical Dental Vision
Dependent



M F

Medical Dental Vision
Dependent



M F

Medical Dental Vision
OTHER MEDICAL COVERAGE
SIGNATURE REQUIRED: By signing below, I acknowledge that I have read, understand and agree to the terms and arbitration agreement stated below.
  • On behalf of myself and my eligible Dependents, I hereby apply for health coverage offered by MediExcel Health Plan through my Employer and agree to be bound by the MediExcel Health Plan Group Subscriber Agreement, Evidence of Coverage and Disclosure Form, and this Enrollment Form.
  • I attest the information provided in this application is true and complete.
  • I attest that I and my enrolling dependents (if applicable) have the necessary border crossing documents to cross into Mexico to access healthcare.
  • MANDATORY BINDING ARBITRATION: I understand that MediExcel Health Plan uses mandatory binding arbitration to resolve disputes. I am agreeing to arbitrate claims that relate to my or a dependent’s membership in MediExcel Health Plan (except for Small Claims Court cases and claims that cannot be subject to binding arbitration under governing law.) I understand that any dispute between myself, my heirs, relatives, or other associated parties on the one hand and MediExcel Health Plan, any contracted health care providers, administrators, or other associated parties on the other hand for alleged violation of any duty arising out of or related to membership in the Health Plan, including any claim for medical or hospital malpractice (a claim that medical services were unnecessary or unauthorized or were improperly, negligently or incompletely rendered), for premises liability, or relating to the coverage for, or delivery of, services or items, irrespective of legal theory, must be decided by binding arbitration under California law and not by lawsuit or resort to court process, except as applicable law provides for judicial review of arbitration proceedings. I agree to give up our right to a jury trial and accept the use of binding arbitration. I understand that the full arbitration provision is in the MediExcel Health Plan Evidence of Coverage, which is available for my review.


Print Name of Subscriber or Authorized Party:

or
MediExcel © 1994-2020. All Rights Reserved. Av. Paseo de los Heroes 2507, Zona Rio, Tijuana BC | 664.633. 8300 San Diego | 619 365.4346 |