Self-Reporting Form - Blue Cross Blue Shield Of Rhode Island
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1BlueCHiP For Healthy Options
Self-Reporting Form
Small Group Underwriting - 00132
IMPORTANT: To maintain BlueCHiP for Healthy Options’ Advantage level benefits,
Blue Cross & Blue Shield of
this form must be completed and mailed to the address at right no later than 240 days
Rhode Island
(eight months) after enrollment. If we do not receive a Self-Reporting Form for each
500 Exchange Street
adult (aged 18 and older) family member within 240 days of enrollment, the entire
Providence, RI 02903-2699
family will be enrolled in Basic level benefits.
Member Name: __________________________________________
Member Identification Number: _____________________________
Address: _______________________________________________
Date of Birth: ____________________________________________
__ _____________________________________________________
To qualify for Advantage level benefits, you must confirm your participation in any necessary wellness program(s).
Please fill in the appropriate information.
1.
Smoker/Tobacco User
❏
2.
Weight Management
❏
Yes
Yes,
on my PCP Checklist, my primary
care physician (PCP) recommended that I participate in a weight management program.
I, _______________________________________________ ,
I, _______________________________________________ ,
member name
confirm that I am participating in a smoking/tobacco cessation
member name
confirm that I am participating in the applicable weight management
program.
program(s) as directed by my PCP.
Today’s date is ______________________________________ ,
Today’s date is ______________________________________ ,
and I understand my participation in the Advantage level of benefits
and I understand my participation in the Advantage level of benefits
is dependent on my engagement in this/these program(s).
is dependent on my engagement in this/these program(s).
_______________________________________
Actions Taken:
______________________________________
Action(s) Taken:
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
___________________________________
Member Signature:
____________________________________
Member Signature:
Smoker/Tobacco User
❏
Weight Management
❏
No
No,
my PCP did not recommend that
I participate in a weight management program.
I, _______________________________________________ ,
I, _______________________________________________ ,
member name
confirm that I currently am not a smoker, yet I understand that
member name
if I start smoking and/or start using tobacco, I will participate in
confirm that I maintain a healthy weight, according to my PCP.
a smoking/tobacco cessation program.
Today’s date is ____________________________________ ,
Today’s date is ____________________________________ ,
and I understand my participation in the Advantage level of benefits
and I understand my participation in the Advantage level of benefits
is dependent on my compliance with this statement.
is dependent on my compliance with this statement.
____________________________________
___________________________________
Member Signature:
Member Signature:
You can download blank
Self-Reporting Forms from .
BlueCHiP for Healthy Options complies with
the Rhode Island Office of the Health Insurance
Commissioner’s (OHIC) requirements for a
500 Exchange Street
Providence, RI 02903-2699
•
HEALTHpact plan. HEALTHpact plans are
designed to assist small employers in offering
Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association.
health coverage that encourages members to
make healthy lifestyle choices by meeting
06/12
BCHP-11518 • 5766
certain Wellness Participation Requirements.
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