Small Group Member Application Form Page 2
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4Section 3 Health Plan Options
Plan Type
c Dental:
c Vision:
c Medical:
c Individual c Family
c Individual c Family
c Individual c Family
By completing this application you will be enrolled in VantageBlue Select.
Section 4
Spouse or Domestic Partner Information
Last name
First name
_______ M.I.
Suffix
Coverage applied for: c Medical c Dental c Vision
Home address (if different from applicant)
Date of birth (mm/dd/yyyy) ___ / ___ / ______
Gender c M c F
Social security number
-
-
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Home phone number
-
-
Cell phone number
-
-
E-mail address
Primary care physician (PCP) name, address
________________________________________________________________
2
________________________________________________________________________________________________________ _
Is this dependent a current patient of the PCP listed above? c Yes c No
Section 5
Dependent Information
Dependent #1
Last name
First name
_______ M.I.
Suffix
Relationship c Son c Daughter
Coverage applied for: c Medical c Dental c Vision
Date of birth (mm/dd/yyyy) ___ / ___ / ______
Social security number
-
-
1
Primary care physician (PCP) name, address
________________________________________________________________
2
_________________________________________________________________________________________________________
Is this dependent a current patient of the PCP listed above? c Yes c No
Dependent #2
Last name
First name
__ M.I.
Suffix
Relationship c Son c Daughter
Coverage applied for: c Medical c Dental c Vision
Date of birth (mm/dd/yyyy) ___ / ___ / ______
Social security number
-
-
1
Primary care physician (PCP) name, address
_____________________________________________________________
2
______________________________________________________________________________________________________
Is this dependent a current patient of the PCP listed above? c Yes c No
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Social Security number is required in order to comply with the reporting requirements of the Mandatory Insurance Reporting Law.
See
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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)
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Parent category: Medical