Application To Reapply For Coverage printable pdf download

Essential Blue Freedom

Application to Reapply for Coverage

(For Current Policyholders Only)

READ ALL INSTRUCTIONS BEFORE COMPLETING THIS APPLICATION. APPLICATION MUST BE

COMPLETED IN ITS ENTIRETY

AND ALL PAGES MUST BE SUBMITTED

IN ORDER TO BE PROCESSED.

This form is a legal document. If you are approved for coverage, it will become a part of your

contract. Therefore, all information provided must be accurate and legible.

• This application must be completed in dark blue or black ink. Applications completed in pencil

will not be accepted.

• If you make a mistake, mark through the incorrect information, initial it, date it, and provide the

correct information.

• Do not use liquid paper, correction tape, or "white out" to correct any mistakes on this application.

• Any attachments submitted with the application must be signed and dated. Please also include

your Member ID number on each page.

• Do not send any money with this application.

• Please ensure all required parties have signed and dated the application prior to submission.

• We strongly recommend you make a copy of this completed application for your records.

INSTRUCTIONS

Eligibility: If you are an Essential Blue Freedom policyholder, your policy will terminate 364 days from the effective

date. If your need for coverage extends beyond the termination date of this plan, you may apply for a new Essential

Blue Freedom plan.

When you are completing this form, please refer to your Arkansas Blue Cross and Blue Shield identification card

for your Member ID and Group #. This information must be entered under Section 1 in order to process your request.

Effective Date: If your application is submitted at least 15 days prior to the termination date of your existing policy and

approved, your effective date can be coordinated with the termination date of your current policy. For example, if your

current policy ends on July 15

, your new policy will be effective July 16

. If we do not receive your reapply application

15 days prior to your termination date, your current policy will be terminated on the policy end date.

Section 3 – Address Information

You are required to provide address information when submitting this application. Please note there are three separate

listings for this information. Complete all that apply.

• Residential – This address will be noted as your physical place of residence.

• Mailing – Correspondence such as letters and Explanations of Benefits (EOBs) will be mailed to this address.

• Billing – All billing invoices will be mailed to this address.

Section 4 – Medical Questionnaire

If you are not sure if you fall into the acceptable ranges referenced in this section, please contact your physician to

assist you.

Form No. EBF Reapply DR (06/14)

Application To Reapply For Coverage