C15390-Hl Health & Life Employee Enrollment Application Form Page 2
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2
3Date of birth _____ /_____ /__________
Gender c Male c Female
Marital status c Single c Married c Domestic partner
Language preference: c English c Spanish c Chinese c Vietnamese c Other __________
Are you enrolling your spouse/domestic partner and/or child dependents
c Yes c No If yes, complete Section 4 of application.
HMO provider information: Blue Shield of California directory website:
Name of primary care physician (PCP):
Provider number:
IPA/medical group number:
Existing patient? c Yes c No
Name of dental provider:
Dental provider number:
Existing patient? c Yes c No
Section 4 – Dependent spouse/domestic partner/children information
If you, your spouse/domestic partner, or
your dependents are refusing coverage, please complete and sign the Refusal of Personal Coverage form.
Dependent’s address, if different from employee’s address – Please indicate which dependent(s) this applies to:
Enroll in
Enrolling spouse/domestic
Access+ HMO and Added Advantage
(please check
Dental HMO only – dental provider
partner information
POS only – name of Personal Physician
all that apply)
c Spouse c Domestic partner
c Medical
Doctor’s name
Dental provider name
c Dental
c Male
c Female
c Vision
First
First
c Basic life/
AD&D
First
MI
Last
Last
$________
c Supp.
Last
life (I/A)
Provider number
Dental provider number
$________
Social Security number
c Supp.
IPA/medical group number
AD&D (I/A)
Date of birth (mm/dd/yyyy)
$________
Existing patient? c Yes c No
Existing patient? c Yes c No
Enroll in
Enrolling dependent child(ren)
Access+ HMO and Added Advantage
(please check
Dental HMO only – dental provider
information
POS only – name of Personal Physician
all that apply)
c Male c Female
c Medical
Doctor’s name
Dental provider name
c Dental
c Vision
First
First
First
MI
c Basic life/
AD&D
Last
Last
$________
Last
c Supp.
life (I/A)
Provider number
Dental provider number
Social Security number
$________
c Supp.
Date of birth (mm/dd/yyyy)
IPA/medical group number
AD&D (I/A)
$________
Disabled? c Yes c No
Existing patient? c Yes c No
Existing patient? c Yes c No
c Male c Female
c Medical
Doctor’s name
Dental provider name
c Dental
c Vision
First
First
First
MI
c Basic life/
AD&D
Last
Last
$________
Last
c Supp.
life (I/A)
Provider number
Dental provider number
Social Security number
$________
c Supp.
Date of birth (mm/dd/yyyy)
IPA/medical group number
AD&D (I/A)
$________
Disabled? c Yes c No
Existing patient? c Yes c No
Existing patient? c Yes c No
C15390-HL
Employee enrollment application (for 51+ employees)
Page 2 of 3
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