Form 5414 - Personal Doctor Selection Form
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Failure to fill out this form completely may result in a delay of coverage and issuance of ID cards.
Personal Doctor Selection Form
Use this form to elect your Personal Doctor.
• A Personal Doctor must be chosen for each family member; females may also select a participating OB/GYN. (If an OB/GYN is not selected, your Personal Doctor should provide these services.)
• You may change your Personal Doctor or OB/GYN by submitting this form or calling the customer service number on your ID card. Personal Doctor election changes will be effective the first of the
month following receipt of your request.
A. Employer Information
Group/Billing Unit No. _____________________________________________________________ Group Department No. ______________________________________________________________
Employer Name: __________________________________________________________________________________________________________________________________________________
Employer Address: __________________________________________________________________ City: ___________________________________ State: ____________ Zip: ________________
B. Employee Information
Name (First, Last): _______________________________________________ Social Security Number:_________________________ Effective Date of Personal Doctor Selection: ______/______/______
1
C. Personal Doctor Selection
OB/GYN
Personal Doctor
OB/GYN Personal
Gender
Are you an
OB/GYN Personal
Personal Doctor
Are you an
Full Name
Date of Birth
Provider
Personal Doctor Name
Address (Office
(Check
established
Doctor - Provider
Doctor Name
Address (Office
established
(First and Last Name)
location where you will
(First, Last)
MM/DD/YY
Number
2
2
one)
patient?
(First and Last Name)
location where you
patient?
Number
receive services)
will receive services)
Employee
□ M
□ Yes
□ Yes
/
/
□ F
□ No
□ No
__ __ __ __ __
__ __ __ __ __
Dependent
□ M
□ Yes
□ Yes
/
/
□ F
□ No
□ No
__ __ __ __ __
__ __ __ __ __
Dependent
□ M
□ Yes
□ Yes
/
/
□ F
□ No
□ No
__ __ __ __ __
__ __ __ __ __
Dependent
□ M
□ Yes
□ Yes
/
/
□ F
□ No
□ No
__ __ __ __ __
__ __ __ __ __
Dependent
□ Yes
□ M
□ Yes
/
/
□ F
□ No
__ __ __ __ __
__ __ __ __ __
□ No
Dependent
□ M
□ Yes
□ Yes
/
/
□ F
□ No
□ No
__ __ __ __ __
__ __ __ __ __
1 HMO and Blue Rewards plans require a Personal Doctor be selected.
2 If you are not an established patient, you will need to determine if this Personal Doctor is accepting new patients. If the provider you listed is not accepting new patients, you will need to
select a different Personal Doctor. To access a Provider Directory, see
N-5414 10/15
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Parent category: Business