Enrollment Form - Blue Advantage, Arkansas

P.O. Box 1460

ENROLLMENT FORM

Little Rock, Arkansas 72203-1460

EMPLOYMENT AND COVERAGE INFORMATION

NAME OF EMPLOYER

GROUP #

TYPE OF COVERAGE

BENEFIT PLAN SELECTED

EFFECTIVE DATE

IS THIS A LATE ENROLLMENT

*

SINGLE MEDICAL

FAMILY MEDICAL

STANDARD

PCN/PPO

SINGLE DENTAL

FAMILY DENTAL

YES

NO

PCN

PPO

SINGLE COBRA

FAMILY COBRA

OTHER___________________________________

EMPLOYEE INFORMATION

FOR EMPLOYER USE ONLY

PREEXISTING CONDITIONS

BIRTH DATE

DATE OF HIRE

SELECTED PCN

SEX

LAST NAME

FIRST NAME

M.I.

SOCIAL SECURITY NUMBER

EXCLUSION PERIOD

MO.

DAY

YR.

MO.

DAY

YR.

PHYSICIAN*

M/F

EXPIRATION DATE

–

–

Are you a current, active employee?

Yes

No

If No, retirement date:__________________________________________________________________________

CURRENT MAILING ADDRESS

STREET OR P.O. BOX

CITY

STATE

ZIP CODE

COUNTY

COMPLETE FOR FAMILY COVERAGES ONLY:

EMPLOYEE AND SPOUSE

EMPLOYEE AND CHILDREN

EMPLOYEE AND FAMILY

FOR EMPLOYER USE ONLY

**FULL-

BIRTH DATE

DEPENDENT

SEX

RELATIONSHIP

SELECTED PCN

HANDI-

LAST NAME

M.I.

PREEXISTING CONDITIONS

FIRST NAME

TIME

SOCIAL SECURITY NO.

MO. DAY YR.

M/F

TO EMPLOYEE

PHYSICIAN*

CAPPED

EXCLUSION PERIOD

STUDENT

EXPIRATION DATE

**NAME OF ACCREDITED COLLEGE OR UNIVERSITY ____________________________________________SEMESTER FOR WHICH STUDENT IS ENROLLED_____________________ NUMBER OF HOURS ENROLLED PER SEMESTER__________________

OTHER INSURANCE INFORMATION

Spouse’s Employer:

Do you or any member of your family have other health/dental insurance?

Yes

No

Medicare

Blue Cross/Blue Shield

Spouse’s Date of Birth:

If Medicare, reason for coverage:

Over 65

Disabled

Kidney Disease Medicare effective date:______________________________

If yes, please indicate: Policy Holder________________________________________________ Policy #____________________________________________

Type of Coverage:

Medical

Dental

Insurance Co. Name_____________________________________________________________________________________________

Single

Single

Insurance Co. Address___________________________________________________________________________________________

Family

Family

IMPORTANT: ALL APPLICATIONS MUST BE SIGNED

PLEASE SIGN BELOW:

I hereby authorize any providers of health care services, claim administrators, insurers, reinsurers, and others who have a legitimate need for such information for the purpose of review, investigation, or evaluation of a

claim,

to supply each other with information about my health status and health care services provided to me. I agree that a photographic copy of this authorization is as valid as the original. I also release to BlueAdvantage

Administrators of Arkansas any and all information relative to Title XVIII Medical Claims, or claims with other benefit plans or insurance companies, by or on behalf of me or any covered member of my family, in order to coordinate

benefits with this plan.

If you are enrolling in a PCN program:

I have read and understand the material provided explaining The Primary Care Network and have elected to enroll in this program. I understand that no PCN services (except life threatening or unless otherwise specified by your

plan document) will be covered without being authorized by the Primary Care Physician listed on this application for myself and any eligible family members. I further recognize that I have the right to voluntarily change primary care

physicians participating in The Primary Care Network without losing the additional benefits available under this program. I understand that should I, or a family member covered under my contract, fail to adhere to the provisions

of the Primary Care Network Program, I could be forced to return to the standard benefits program offered through my employer or be forced to encounter additional out-of-pocket expense due to reduced benefit payment.

I further authorize payment direct to my primary care physician, referred physician, hospital or other medical provider for the medical benefits otherwise payable to me.

I understand that all determinations affecting the quality of medical care will be solely between myself and my physicians.

*

EMPLOYEE SIGNATURE_______________________________________________ EMPLOYER SIGNATURE_______________________________________________

ENROLLMENT DATE________________________________

BAAA53-01