Enrollment And Change Form

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Enrollment and Change Form
Please Read The Instructions
Before Filling Out This Form.
Please mail to: BCBSMA, P.O. Box 9145,
North Quincy, MA 02171-9145 or fax 617-246-7531
Please PRINT CLEARLY using blue or black ink
Blue Cross Blue Shield of Massachusetts is an
to avoid coverage delay or type in information.
Independent Licencee of the Blue Cross and Blue Shield Association
1. To Be Filled Out by Your Employer
Company
Current Medical Group #:
Medical Group #, Transferring To
Name
Current BCBS ID #, If any
Requested Effective Date
Date of Hire
Current Dental Group #:
Dental Group #, Transferring To
MM
DD
YYYY
MM
DD
YYYY
(If canceling, please see
Remarks: (i.e., qualifying event for a new add, change to family or other instruction)
Type of
instructions for three digit
Transaction
termination code.)
Open Enrollment
Change to Family
Loss of Coverage
ADD
New Hire
Add Spouse
(HIPAA Continuation of Coverage Letter Required )
CHANGE
COBRA
Add Dependent
TRANSFER
Other________________________________________
CANCEL
2. Tell Us About Yourself ( Member 1 )
What
Kind of Membership
Kind of Membership
HMO Blue
Dental Blue
HMO Blue New England
Products are
(Medical)
(Dental)
Network Blue
Access Blue
Blue Choice New England
you selecting?
Individual
Individual
Blue Choice
PPO
Other (
Write Name of Plan)
Family
Family
Saver Product
Your First Name
M.I.
Last Name
Sex
Date of Birth
Street Address / P.O. Box #:
Apt. #:
City / Town
State
Zip Code
Social Security #:
Telephone #: (area code)
Other Insurance? *
Other Insurance Company Name
City / State
(
)
Y
/ N
PCP ID #: (see instructions)
Name of PCP
City/State
Is this your current PCP?
Mark X, if yes.
Are you Covered
Medicare #:
Actively Working
Part A Effective Date
Part B Effective Date
Part D Effective Date
by Medicare? *
Y
/ N
If Retired, Date:
Y
/ N
65+
Disabled
ESRD
MM
DD
YYYY
MM
DD
YYYY
MM
DD
YYYY
Spouse
Domestic Partner
Divorced Spouse (court ordered)
3. Tell Us About ( Member 2 )
Please check one:
Member 2’s First Name
M.I.
Last Name
Sex
Date of Birth
Street Address / P.O. Box #:
Apt. #:
City / Town
State
Zip Code
Social Security #:
Telephone #: (area code)
Other Insurance? *
Other Insurance Company Name
City / State
(
)
Y
/ N
PCP ID #: (see instructions)
Name of PCP
City/State
Is this your current PCP?
Mark X, if yes.
Is Member 2
Medicare #:
Actively Working
Part A Effective Date
Part B Effective Date
Part D Effective Date
Y
/ N
Covered by
Medicare? *
If Retired, Date:
Y
/ N
65+
Disabled
ESRD
MM
DD
YYYY
MM
DD
YYYY
MM
DD
YYYY
* If you have not indicated Yes or No regarding your Medicare or other insurance status, you may receive a follow-up questionnaire.
4. Tell Us About Your Dependents ( Member 3, 4, and 5 )
Dependent’s First Name
M.I.
Last Name
Sex
Full-time student?
3.)
Age 19 or Over
Y
/ N
Social Security #:
Date of Birth
PCP ID #: (see instructions)
Name of PCP
Is this your current PCP?
Mark X, if yes.
Dependent’s First Name
M.I.
Last Name
Sex
Full-time student?
Age 19 or Over
Y
/ N
4.)
Social Security #:
Date of Birth
PCP ID #: (see instructions)
Name of PCP
Is this your current PCP?
Mark X, if yes.
Dependent’s First Name
M.I.
Last Name
Sex
Full-time student?
5.)
Age 19 or Over
Y
/ N
Social Security #:
Date of Birth
PCP ID #: (see instructions)
Name of PCP
Is this your current PCP?
Mark X, if yes.
Please check if you are using separate forms for additional dependent children.
Total # of Dependents :
5. Select Personal Savings Account ( Blue Healthcare Bank Members Only )
6. Signature ( Employer & Employee )
The information here is complete and true. I understand that Blue Cross and Blue Shield will rely on this information to enroll me and my dependents or to make changes to my
membership. I understand that I should read the subscriber certificate or benefit booklet provided by my employer to understand my benefits and any restrictions that apply to my
health care plan. I understand that Blue Cross and Blue Shield may obtain personal and medical information about me to carry out its business, and that it may use and disclose that
information in accordance with law. I acknowledge that I may obtain further information about the collection, use and disclosure of my information in “Our Commitment to
Confidentiality,” Blue Cross and Blue Shield’s notice of privacy practices.
______________________________________________________
___________________________________________________________________
Employee’s Signature
Date
Employer’s Signature
Date

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