Fillable Subscriber Change Request Form printable pdf download

Subscriber Change Request

Blue Shield of California and

Blue Shield of California Life & Health Insurance Company

All changes must be received within 31 days of the effective date of change. This form cannot be used for primary care physician (PCP) changes –

subscriber must call the Member Services phone number on the back of their ID card.

Employee identification – this section must be completed.

Subscriber ID number (from ID card)

Social Security number

Group number (from ID card)

Work telephone

Home telephone

Last name

First name

Home street address – City

State

ZIP code

Group/employer name (if applicable)

E-mail address

Changes

c Yes

c No Is this a change/correction of address?

c Yes

c No Is the change/correction of address for a dependent? (Note: Dependent’s address will default to subscriber’s address if ‘No’ is indicated here.)

If yes, please indicate dependent name and address change: _________________________________________________________________________________________

c Correct my Social Security number to: _________________________________________________ (Copy of Social Security card, a photo ID, a letter of verification

from the Social Security office, and a written statement of why the employee is requesting the change must be attached.)

c This is a change made during open enrollment.

c Transfer/add my health coverage to: c Access+ HMO _______ c Access+ HMO SaveNet _______ c Local Access+ HMO _______

c Added Advantage POS _______

c Full PPO _______

c Active Choice* _______ c Full PPO Savings Plus _______

c Transfer my ABHP benefits coverage to:

For Access+ HMO: c HRA c HIA c FSA

For Local Access+ HMO: c HRA c HIA c FSA

For Full PPO c HRA c HIA c FSA

For Full PPO HSA: c HRA c HIA c FSA c HSA c LFSA

For 51-100 Small Group Transition plans, transfer/add my health coverage to: c HMO c PPO c PPO for HSA

c Transfer my ABHP benefits coverage to:

For HMO: c HRA c HIA c FSA

For PPO: c HRA c HIA c FSA

For Shield PPO Savings Plus for HSA: c HRA c HIA c FSA c LFSA

Transfer my specialty benefits coverage to: c DHMO _______ c DPPO _______ c DINO _______

From Group No. _________ to Group No. _________ in my employer group. Note: If transferring coverage to HMO, POS, or DHMO, please complete Section A.

c Change the amount of Basic Group Term Life or Supplemental Life and Supplemental AD&D insurance coverage: (provide prior coverage amount

and new coverage amount)

Prior amount of Basic Group Term Life coverage: $ ____________________

New amount of coverage: $ ____________________

Prior amount of Supplemental Life and/or Supplemental AD&D coverage: $ ____________________

New amount of coverage: $ ____________________

(If Supplemental AD&D coverage is purchased, it is always in the same amount as the Supplemental Life coverage)

c Correct/change name to:

c Correct/change email address to:

c Correct/change my date of birth from: ___________________ to: ___________________

c Additional changes/comments: _________________________________________________________________________________________________

c Subscriber cancellation: I decline health plan coverage for myself (and dependents, if any) effective: ___________________

c COBRA participant

c Qualifying event ________________________________________________________________________________________________________________

c Effective date of above qualifying event: _______________________________________________________________________________________

c Is this a termination? If yes, list name(s): __________________________________________________________________________________________

Spouse/domestic partner/dependent child(ren) coverage changes

Add spouse/domestic partner/dependent child(ren) – Complete section A – Requested effective date for additions: ___________________

c Date of marriage if adding spouse: ___________________

c Domestic partner – date of domestic partnership if adding_________________

c If court ordered custody/coverage, enter date and attach copy of legal documents: ___________________

c If adoption, enter date of adoption or date placed for adoption, and attach copy of legal documents: ___________________

c Disabled dependent over the age of 25 (Attach a ‘Declaration of disability for over age dependent child’ form (C3674) or confirmation that your

current health carrier is providing coverage for this disabled dependent.)

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Subscriber Change Request Form

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