Blue Cross Blue Shield Membership Application Template
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1Blue Cross Blue Shield Membership Application
1.
Please indicate reason for Application:
New Member(s)
Coverage Change
Cancel
Miscellaneous
COBRA:
18-Mo.
29-Mo.
36-Mo. (Block 17 must be completed)
Transfer Within Your Group From ________________________
Left Employment:
Wants Conversion or Medical Complementary Info
Deceased
Name Change
Department / Payroll Number Change
Address Change
Social Security Number Change From _____________________________
ID Card Request
Add Dependents
Return From Layoff/Medical Leave
Other ______________________________________
2.
EFFECTIVE DATE OF ACTION REQUESTED:
DATE OF HIRE:
ELIGIBILITY DATE:
Month ____ Day_____ Year _____
Month ____ Day _____ Year _____
Month ____ Day ____ Year _____
3.
Type of Contract:
PPO
IDENTIFICATION
4.
Employee – Last Name
First
Initial
Home Telephone No.
5.
Social Security No.
6.
Mailing Address (Street or P.O. Box)
(City)
(State)
(Zip Code)
(County Code)
7.
Name of Employer
8. Blue Cross Group Number
9. Dept No.
10. Payroll No.
-
-
-
REASON FOR COVERAGE CHANGE
11. Check appropriate reason; give occurrence date in Block 13:
12. Name of spouse to be
13.
Occurrence Date or
excluded from coverage
Left Employment Date
A
Birth or Adoption
C
Divorce
if applicable
Mo.
Day
Yr.
B
Death (Name:______________ )
D
Marriage
E
Other – Explain: ____________
______________________
_____________________
TYPE MEMBERSHIP AND COVERAGE INFORMATION
14. Check type membership for each coverage desired. (Indicate life coverage desired, if applicable, in blocks 15 through 19.)
a.
b.
c.
REFUSAL OF HEALTH COVERAGE
HEALTH
DENTAL
01
Other Insurance with BCBS
11
Non-federally qualified HMO
S – Single
02
Insurance with another company
12
Covered by Medicare
F – Family
03
US military coverage
13
Covered by CHAMPUS
F – Employee/Children
04
Federally qualified HMO
05
Other – Explain: _________________
8 – Employee/Spouse
07
My spouse’s coverage with this group
09
Other third-party administrator
15. If Sponsored Membership, give Sponsor’s Social Security No. _______________________________
16. List All Family Members Covered or Affected By a Change
Birthdate
Birthdate
Last Name
First
Initial
Sex
Last Name
First
Initial
Sex
Mo. Day
Yr.
Mo. Day
Yr.
YOURSELF:
Spouse
Child
Social Security No.
Social Security No.
Child
Child
Social Security No.
Social Security No.
Child
Child
Social Security No.
Social Security No.
Child
Child
Social Security No.
Social Security No.
OTHER INSURANCE INFORMATION
17.
Do you or does any member of your family have other health, dental or drug coverage, Federal Employees’ Program (FEP) or Medicare?
YES
NO
If Yes:
MEDICARE A
Effective Date _________________
MEDICARE B
Effective Date__________________
A. Family Member’s Name ____________________________________________
and Social Security Number ___________________________
B. Name of Insurance Co. ________________________________
Policy No.______________________
Effective Date __________________
C. Family Member’s Employer _____________________________________________________________________________________________
D. List Names of Covered Persons 1. ____________________ 2. _____________________ 3. __________________ 4. ___________________
E. Please circle each type of service covered by this policy: Hospital, Physician / Medical, Prescription Drugs, Dental, Vision
EMPLOYEE CERTIFICATION
18. Employee Certification
I HAVE READ AND UNDERSTAND EACH AND EVERY PART OF THIS ENROLLMENT APPLICATION.
Date: ___________________
Signature: ______________________________________________________________________
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