Access Enrollment/change Form
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1
2BLUECARE ACCESS ENROLLMENT/
All Information Must Be
Provided, Please Print In
CHANGE FORM
Ink or Type
An Independent Licensee of the Blue Cross and Blue Shield Association
Group Benefit Administrators (GBA) enrolling new employees may submit this form online at
GBA or employee may complete all other transactions using our interactive PDF
REQUESTED EFFECTIVE DATE
at Type information in, print, sign and submit one of three ways,
email: , fax: (802) 371-3329, or mail: BCBSVT P.O. Box 186 Montpelier, VT 05601.
/
/
SECTION 1 - EMPLOYER/EMPLOYEE INFORMATION
EMPLOYER NAME
ACCOUNT NO. (eight to nine characters i.e. 12345000 or T12345650)
SOCIAL SECURITY NO.
LAST NAME
FIRST NAME
MAILING ADDRESS
CITY
STATE
ZIP CODE
CONTACT NUMBER
E-MAIL ADDRESS (REQUIRED)
EMPLOYMENT STATUS
ACTIVE
RETIRED
CONTINUATION
DATE HIRED/REHIRED/or BECAME FULL TIME
MARITAL STATUS
HEALTH COVERAGE TYPE ( *Includes Party to a Civil Union or Domestic Partner )
SINGLE
MARRIED/PARTY TO A CIVIL UNION
EMPLOYEE ONLY
EMPLOYEE/SPOUSE*
DOMESTIC PARTNER**
DIVORCED
WIDOWED
EMPLOYEE/CHILD
EMPLOYEE/CHILDREN
FAMILY
SECTION 2 - NEW ENROLLMENT
(Check one, then go to SECTION 5)
NEW HIRE
RE-HIRE
CONVERT TO MEDICARE SUPPLEMENT** (Attach copy of Medicare Card)
SPOUSE TURNING AGE 65
OPEN ENROLLMENT
CONTINUATION OF COVERAGE (COBRA/VIPER)
REFUSAL
NEW GROUP
TRANSFERRED FROM ANOTHER BCBSVT PLAN Transferring From Certificate No. _________________________________________________________
SECTION 3 - CHANGE
(Check all that apply)
DATE OF EVENT _____________________ REASON FOR CHANGE EVENT
BIRTH
ADOPTION
MARRIAGE/CIVIL UNION
DIVORCE
DEATH
LOSS OF COVERAGE**
ENTER/DISCHARGE FROM MILITARY
COURT ORDERED CHANGE**
ADD/REMOVE SPOUSE/PARTY TO CIVIL UNION OR DEPENDENT (List in SECTION 5)
ADDRESS CHANGE
NAME CHANGE
PCP CHANGE
OTHER (explain)_______________________________________________________________________________________________
SECTION 4 - POLICY CANCELLATION - Signature Required
SIGN HERE BELOW:
VOLUNTARY CANCEL
LEFT EMPLOYMENT
(Subscriber Signature)
(Group Benefits Manager Signature)
X
CANCEL CONTINUATION COVERAGE
OTHER, explain____________________________
(Subscriber or Group Benefits Manager)
(Subscriber Signature)
SECTION 5 - LIST ALL MEMBERS BELOW TO BE ADDED OR REMOVED
IMPORTANT NOTE: Federal Law mandates our collection of Social Security Numbers (SSN).
If you are adding a dependent child, age 26 or older,
contact Customer Service (800) 247-2583 for further instructions.
MEMBER INFORMATION
PRIMARY CARE PHYSICIAN (PCP) INFORMATION
(
)
PCP Name
PCP Phone No.
ADD
REMOVE - Subscriber
Resides Outside BCA Area
LAST NAME
FIRST NAME
SSN***
Male
City
ST
Female
DOB
Are you a current patient?
Yes
No
(
)
PCP Name
PCP Phone No.
ADD
REMOVE - Spouse/Party to a Civil Union
Resides Outside BCA Area
LAST NAME
FIRST NAME
SSN***
Male
City
ST
Female
DOB
Are you a current patient?
Yes
No
(
)
PCP Name
PCP Phone No.
ADD
REMOVE - Dependent Child
Incapacitated dependent 26/older
Resides Outside BCA Area
LAST NAME
FIRST NAME
SSN
Male
City
ST
Female
DOB
Are you a current patient?
Yes
No
PCP Name
PCP Phone No.
(
)
ADD
REMOVE - Dependent Child
Incapacitated dependent 26/older
Resides Outside BCA Area
Male
LAST NAME
FIRST NAME
SSN
City
ST
Female
DOB
Are you a current patient?
Yes
No
PCP Name
PCP Phone No.
(
)
ADD
REMOVE - Dependent Child
Incapacitated dependent 26/older
Resides Outside BCA Area
LAST NAME
FIRST NAME
SSN
Male
City
ST
Female
DOB
Are you a current patient?
Yes
No
PCP Name
PCP Phone No.
(
)
ADD
REMOVE - Dependent Child
Incapacitated dependent 26/older
Resides Outside BCA Area
LAST NAME
FIRST NAME
SSN
Male
City
ST
Female
DOB
Are you a current patient?
Yes
No
PLEASE SEE SECTION 7 ON PAGE 2 FOR SUBSCRIBER SIGNATURE
* = Includes Party to a Civil Union or Domestic partner
*** = SSN required age 45 and older (Federal mandate requires the collection of SSN)
** = Additional Documentation Required
280.307 (6/12)
PAGE 1 OF 2
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