Small Group Member Application Form Page 4
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4Section 6 Other Insurance and Medicare
Are you or any of your dependents covered by other insurance?
c Yes c No
Name of other insurance company and name(s) of covered person(s):
Covered person 1 ___________________________________________________________________________________
Insurance company ______________________________________________Member ID#1 ______________________
Covered person 2 ___________________________________________________________________________________
Insurance company ______________________________________________Member ID#2 ______________________
What is the name of your prior medical insurance carrier? __________________________________________________
When did your medical coverage end? (mm/dd/yyyy) ___ / ___ / ______
Please attach evidence of prior coverage showing coverage and end date.
Is anyone named in this application eligible for Medicare? c Yes c No
If yes, name of eligible person _________________________________________________________________________
Is the eligible person c Over 65 c Disabled
Retired date (if applicable)________________________________
Medicare number__ __ __ - __ __ - __ __ __ __ - _____
Effective dates: Part A (hospital): ______________________ Part B (medical): _______________________________
Section 7 Signature
I understand and acknowledge that in choosing the VantageBlue Select plan, I have chosen a plan with a specified
network of providers and that I have reviewed the list of primary care physicians, hospitals, obstetrician/gynecologists
and pediatricians in the network at Although I may choose to go to providers
outside of the network, in order to get the lowest out-of-pocket costs, I have to get services from providers (including
hospitals, specialists, labs, and durable medical equipment suppliers) from the VantageBlue Select network. If I get
a referral to see an out-of-network provider, my out-of-pocket costs will be the same as if I go to a provider in the
VantageBlue Select network. I understand that if I do not get a referral to see an out-of-network provider, other
than for emergency care, my out-of-pocket costs will be higher.
sign
Signature of Applicant or signature of parent or guardian
Date
here
+
if applicant is under 18 years of age
Application rec’d date_____________ ID #____________________
500 Exchange Street
Providence, RI 02903-2699
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Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association.
10/15
PER-17288
VBSAPP (10/15)
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