Enrollment And Change Form - Bcbs Massachusetts
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1Please Read the Instructions
Enrollment and Change Form
Before Filling Out This Form.
Please TYPE OR PRINT CLEARLY using blue
Please mail to: P.O. Box 986001
or black ink to avoid coverage delay or type in information
Boston, MA 02298 or fax to 1-617-246-7531
1. To Be Filled Out by Your Employer
Medical Group #, Transferring To
Company
Current Medical Group #:
Alnylam Pharmaceuticals
Name
---------
6696174
Current BCBS ID #, If any
Requested Effective Date
Date of Hire
Current Dental Group #:
Dental Group #, Transferring To
N/A
N/A
MM
DD
YYYY
MM
DD
YYYY
Type of Transaction
Remarks: (i.e., qualifying event for a new
add, change to family or other instruction)
ADD
CANCEL
❒
❒
Change to Family
❒
Open Enrollment
❒
Loss of Coverage (HIPAA Continuation of Coverage Letter Required)
CHANGE
Three digit
❒
❒
Add Spouse
❒
New Hire
❒
TRANSFER
termination code
Other: __________________________________________
❒
❒
Add Dependent
COBRA
❒
2. Yourself (Member 1)
What
Membership Type
Membership Type
❒
Access Blue
❒
Blue Medicare Rx (Part D)
❒
HMO Blue New England
❒
Network Blue
products?
(Medical)
(Dental)
❒
Blue Choice
❒
Dental Blue
❒
Managed Blue for Seniors
❒
PPO
❒
Individual
❒
Family
❒
Individual
❒
Family
Blue Choice New England
HMO Blue
Medex (Group)
Saver Blue
❒
❒
❒
❒
Your First
M.I.
Last
Sex
Date of Birth
Name
Name
Street Address/
Apt. #
City/
State
Zip Code
P.O. Box #
Town
Home
Cell
Email
Phone (
)
Phone (
)
Social Security #
Other Insurance?
Other Insurance
City / State
2
1
(REQUIRED)
Y
/ N
Company Name
❒
❒
PCP ID #
Name of
City / State
Is this your current PCP?
(see instructions)
PCP
Y
/ N
❒
❒
Are you covered
Part A Effective Date
Part B Effective Date
Part D Effective Date
Medicare #
65+
Disabled
ESRD
❒
❒
❒
2
by Medicare?
If Retired,
Y
❒
/ N
❒
Date
Actively Working? Y
❒
/ N
❒
MM
DD
YYYY MM
DD
YYYY MM
DD
YYYY
3. Member 2
Please Check One: ❒ Spouse ❒ Domestic Partner ❒ Divorced Spouse (court ordered) Plan Type:
❒
Medical
❒
Dental
First
M.I.
Last
Sex
Date of Birth
Name
Name
Social Security #
Phone
City / State
Other Insurance?
1
Other Insurance
1
(REQUIRED)
(
)
Y
/ N
Company Name
❒
❒
PCP ID #
City / State
Is this your current PCP?
Name of
(see instructions)
Y
❒
/ N
❒
PCP
Are you covered
Part A Effective Date
Part B Effective Date
Part D Effective Date
Medicare #
65+
Disabled
ESRD
❒
❒
❒
2
by Medicare?
If Retired,
Y
❒
/ N
❒
Actively Working? Y
❒
/ N
❒
Date
MM
DD
YYYY MM
DD
YYYY MM
DD
YYYY
4. Your Eligible Dependents (Member 3, 4, and 5)
Dependent’s First Name
M.I.
Last
Sex
Date of Birth
3.)
Name
Social Security #
PCP ID # (see
Name of
1
(REQUIRED)
instructions)
PCP
Is this your current PCP? Y
❒
/ N
❒
Full-time student and aged 19 or older
❒
Disabled and aged 26 or older
❒
Plan Type:
❒
Medical
❒
Dental
Dependent’s First Name
M.I.
Last
Sex
Date of Birth
4.)
Name
Social Security #
PCP ID # (see
Name of
1
(REQUIRED)
instructions)
PCP
Is this your current PCP? Y
/ N
Full-time student and aged 19 or older
Disabled and aged 26 or older
Plan Type:
Medical
Dental
❒
❒
❒
❒
❒
❒
Dependent’s First Name
M.I.
Last
Sex
Date of Birth
5.)
Name
Social Security #
PCP ID # (see
Name of
1
(REQUIRED)
instructions)
PCP
Is this your current PCP? Y
❒
/ N
❒
Full-time student and aged 19 or older
❒
Disabled and aged 26 or older
❒
Plan Type:
❒
Medical
❒
Dental
Please check if you are using separate forms for additional dependent children
Total # of dependents: _________________________________
❒
5. Personal Savings Account
Start Date
End Date
FSA Goal Amount (Please
HSA: Health Savings Account
see instructions for limits.): $
Start Date
End Date
Health: $
FSA: Health Flexible Spending Account
Start Date
End Date
Dependent Care: $
FSA: Dependent Care Reimbursement Account
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 _____________
1. REQUIRED: Under the Affordable Care Act, we are required to collect the Social Security number for you and any dependent enrolling in your plan.
2. If you have not indicated Y or N regarding your Medicare or other insurance status, you may receive a follow-up questionnaire.
Blue Cross Blue Shield of Massachusetts is an Independent Licence of the Blue Cross and Blue Shield Association.
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