Form F8046r05 - Bcbs Enrollment Change Form Page 2
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2E. CURRENT AND PREVIOUS COVERAGE –
Failure to fully complete this section may result in a preexisting condition limitation.
Please attach copies of all certificates of prior coverage.
Do you or any family member listed on this application, have any current health coverage or had previous health coverage
within the last 63 days?
Yes
No
If YES you must fully complete the following section
If you or any family member applying for this coverage is currently covered by Blue Cross and Blue Shield of Minnesota,
Blue Plus, USAble Life, MII Life, Inc., or Delta Dental of Minnesota, do you want that coverage canceled?
Yes
No
If YES, provide the individual’s name, identification number, company name, group number and cancellation date:
Starting with the employee, list each family member applying for coverage and include information for all current and
previous coverage in effect during the last 18 months. Make sure to include information for other Blue Cross and Blue Shield
of Minnesota coverage: Use additional sheet if necessary.
Family Member
Insurance Company
Date Coverage
Date Coverage
Reason for
Name
(name and policy number)
Started
Ended
Termination
F. MEDICARE AND OTHER COVERAGE INFORMATION
Will you, or any person listed above be covered by other health insurance or Medicare while enrolled under this coverage?
Yes
No
If yes, you must complete the following: (Medicare: List both Part A and B effective dates)
Name of policy holder
Insurance company
Medicare or
Type of coverage
Effective
and address
policy #
(Single or Family)
date
If Medicare: check reason for entitlement:
Age
Disability
End-Stage Renal Disease
Disability & Current End-Stage Renal Disease
G. COVERAGE CHANGE INFORMATION –
CHECK APPROPRIATE BOX(ES) AND COMPLETE SECTION A, B and C
Adding dependents:
Date of event
Cancelling dependents:
Date of event
Birth/adoption
_________________
Divorce
_____________________________
Court order
_________________
Other
_____________________________
(explain)
Marriage
_________________
County _____________________________
Full-time student
School _______________________________________
Anticipated graduation date ___________
Other
_________________
Details ____________________________________________________________
Loss of prior health and/or dental coverage:
Address change
Did you lose health coverage, dental coverage or both? _________
Primary care clinic change
Date of event
Phone number change
Other coverage voluntarily terminated
________________
Name change
Group continuation (COBRA) period exhausted
________________
Previous _________________________________________
Employer contribution for coverage terminated
________________
List new name in Section A
Coverage terminated due to loss of eligibility
________________ Reason ________________________________________
ENROLLMENT CHANGE FORM SHOULD BE SENT TO:
Blue Cross and Blue Shield of Minnesota and Blue Plus
P.O. Box 64024
St. Paul, Minnesota
55164-0024
Delta Dental of Minnesota is an independent company that does not provide Blue Cross and Blue Shield products and is solely responsible for their dental products.
USAble Life is an independent company that does not provide Blue Cross and Blue Shield products and is solely responsible for their life and disability products.
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