Fillable Access Enrollment/change Form (Page 2 of 2) in pdf

Access Enrollment/change Form Page 2

Download a blank fillable Access Enrollment/change Form in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Access Enrollment/change 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.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

SECTION 6 - OTHER INSURANCE INFORMATION

After you obtain health insurance coverage with us, will you or any of your dependents be covered with another health or dental insurance plan (Including Medicare)?

Yes (If yes, please complete the applicable section below)

If No (Go to SECTION 8)

MEDICARE

NAME of MEDICARE SUBSCRIBER

SOCIAL SECURITY NO.

MEDICARE/HIC NO.

PART A EFFECTIVE DATE

PART B EFFECTIVE DATE

HEALTH

DENTAL

HEALTH INSURANCE COMPANY NAME

DENTAL INSURANCE COMPANY NAME

ADDRESS

POLICY HOLDER NAME

POLICY/CERTIFICATE NO.

POLICY HOLDER NAME

POLICY/CERTIFICATE NO.

EFFECTIVE DATE

TYPE OF COVERAGE

EFFECTIVE DATE

TYPE OF COVERAGE

1 PERSON

2 PERSON

FAMILY

1 PERSON

2 PERSON

FAMILY

SECTION 7 - SUBSCRIBER SIGNATURE

I certify that the statements on this application and all information furnished by me are true and complete to the best of my knowledge. I authorize any health care provider

to disclose to Blue Cross and Blue Shield of Vermont, or its designated agent, any information acquired in connection with my past or future care or treatment or that of

any dependent named herein or hereafter added to my coverage. I understand that no right whatsoever is created by this application and that the same shall not be

considered accepted unless and until the contract is actually issued by Blue Cross and Blue Shield of Vermont. I UNDERSTAND THAT MY BENEFITS ARE GOVERNED

BY THE PROVISIONS OF MY CERTIFICATE AND OUTLINE OF COVERAGE.

SIGN HERE

SUBSCRIBER’S SIGNATURE__________________________________________________________________________________________________________________________

DATE_________________________

You can visit our website at

280.307 (6/12)

PAGE 2 OF 2