Looking for a Dental Forms And Templates? Download it for free!

Individual And Family Dental Change Form (Start Date Of January 1, 2014 Or Later) - Arkansas Blue Cross And Blue Shield Page 2

6 OWNERSHIP CHANGE

From:

First Name________________________ M.I.______Last Name_______________________

To:

First Name________________________ M.I.______Last Name_______________________

7 SPLIT POLICY

Indicate the name of the covered person(s) you want covered on a separate policy with identical coverage.

Reason Code*

First Name

M.I.

Last Name

Suffix

Date of Change

Date of Birth

(see below)

*Reason Codes:

1-Divorce

2-Aging Off

3-Marriage

4-Other (spec

fy above)

Please provide address information for new policyholder ONLY:

Residential Address:

S treet ___________________________________________________________

City ____________________________________ State______ Zip ___________

Mailing Address:

Street ___________________________________________________________

City ____________________________________ State______ Zip ___________

Billing Address:

Street ___________________________________________________________

City ____________________________________ State______ Zip ___________

Please set up the billing mode for my new policy:

Monthly Bank Draft

Monthly Direct Billing

(Must complete attached bank draft form)

(Paper bill)

8 U.S. CITIZENSHIP STATUS

Additional information may be required.

o Yes o No

Are all applicants U.S. citizens?

If "no," please provide the name(s) of the applicant(s) who are not U.S. citizens.

Name:

9 ADDING SPOUSE OR DEPENDENT(S)

Please add the following dependent(s):

IMPORTANT NOTE: Children age 26 and older must apply on their own.

M.I.

First Name

Social Security No.

Last Name

Suffix

Relationship

Sex

Date of Birth

Waiting periods do not apply to children age 18 and under.

The 6-month waiting period for Minor Restorative services (Silver or Gold) and the 6-month waiting period for Major

Restorative services (Gold) will be waived if you meet the following criteria:

1. Your application is received within 30 days of the termination date of your previous coverage; and

2. No later than 60 days from the effective date of your new policy with Arkansas Blue Cross and Blue Shield, you

provide us with a copy of your previous dental policy Certificate of Coverage which reflects the policy’s effective

and termination dates.

You may include these documents with your change form. If you are submitting these documents after

submission of your change form, please fax them to Arkansas Blue Cross at 501-378-3752 or email them to

CRMCustomerService

Page 2

Form No. OE Dental CF (R12/15)

(Continued on page 3)

Individual And Family Dental Change Form (Start Date Of January 1, 2014 Or Later) - Arkansas Blue Cross And Blue Shield Page 2

Related Articles

Related forms

Related Categories