Fillable Small Group Member Application Form printable pdf download

Small Group Member Application Form

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Complete Small Group Member Application Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

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Small Group Member Application

for VantageBlue Select, Dental and Vision Insurance

Please be sure ALL information below is complete to avoid delays in processing.

Please print clearly using blue or black ink or type in information.

Employer Information (To be completed by plan administrator.)

Section 1

Group name

_________Effective date___ / ___ / ______

Date of hire ___ / ___ / ______

Group number

Department number __________________________________________

Choose one:

Add dependent(s)

c Open enrollment

c Spouse

c New hire

c Dependent

c COBRA

( Must apply within 30 days of marriage, birth,

c Loss of coverage (Evidence of prior coverage)

or adoption of dependent.)

c Other___________________________________

Section 2

Employee Information

Last name

First name

_____________ M.I.

Suffix

Home address

City/town

_________ State

ZIP code

Mailing address

Date of birth (mm/dd/yyyy) ___ / ___ / ______

Gender c M c F

Social security number

Home phone number

Cell phone number

Marital status (please check one) c Single c Married c Divorced c Common Law c Civil Union c Domestic Partner

What is your primary language spoken?

E-mail address

Race (please check one)

c Prefer not to answer

c American Indian or Alaska Native c Asian c Black or African American c Hispanic or Latino

c Multiracial c Native Hawaiian or other Pacific Islander c White

Primary care physician (PCP) name, address

_________________________________________________________________

__________________________________________________________________________________________________________

Are you a current patient? c Yes

c No

Social Security number is required in order to comply with the reporting requirements of the Mandatory Insurance Reporting Law.

See

By choosing the VantageBlue Select plan, you must select a Primary Care Physician (PCP) and other healthcare providers (including hospitals, specialists, labs, and durable

medical equipment suppliers) from the VantageBlue Select network in order to get the lowest out-of-pocket healthcare costs (e.g., copayments and coinsurance).

Providers in the VantageBlue Select network can be found at or in the Find A Doctor tool on . If you do not seek services

from a VantageBlue Select network provider or receive a network referral you will be responsible for the applicable higher out-of-network cost sharing.

continued ➤

VBSAPP (10/15)

Small Group Member Application Form

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