Airport Authority

Medical Benefits Scheme

Medical Plan Option Form 2020

Name of Staff: Staff Number:

Position : Department :

Please select a plan from the options below. Change of option is not allowed during the policy year.

Medical Plan Options Please put a “√” below

Free Choice + Network Service

Network Service (HealthNet)

Voluntary Supplementary Major Medical Upgrade (SMM) Plan*

Free Choice + Network Service with SMM reimbursement % upgrade to 90%

*The annual premium for 2020 is $2,304 per head. Please attach a cheque in the appropriate amount payable to the
“Airport Authority”. (Please be reminded that staff member and all eligible dependants must join the plan concurrently.)

Please put a “√” in the following to indicate if you would like to enroll your eligible* family member(s) in the Authority’s
Medical Benefits Scheme. The medical plan option that you have selected will apply to your eligible family member(s).

( ) I would like to enroll my following eligible family member(s) in the Medical Benefits Scheme:

Full Name Relationship

1
2
3
4

( ) I would not enroll my eligible family member(s) in the Medical Benefit Scheme.

( ) I do not have family member(s) eligible for the Medical Benefits Scheme.

Signature Date

Please return this form together with supporting documents (i.e. marriage certificate, birth certificate, full-time education
proof for dependent children aged 19 but under 21), if applicable, to Human Resources Department within 3 working days
from your date of employment. To avoid unnecessary delay in enrollment, please ensure that the data and supporting
documents (if applicable) provided are correct and complete.

Note: The above data are required by the Authority and the medical insurance carrier for medical enrolment and claim administration.

* Please notify the Human Resources Department any changes on the eligibility of dependants with reference to the provisions of the
Medical Benefits Scheme stipulated in the Human Resources Policy Manual.