Form C12914 - Employee Enrollment Application - Blue Shield Of California Page 2
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4Applicant’s Last Name
First Name
MI
Social Security number
Section 3 – Dependent Spouse/Domestic Partner/Dependent Child(ren) information
HMO applicants must select a Personal Physician. Dental HMO applicants must select a dental provider. You may choose a different
Personal Physician for each family member. Be sure to include each physician’s provider number and IPA number, as well as each dental
provider number. * If you, your spouse/domestic partner, or your dependent(s) are refusing coverage, please complete and sign the
Refusal of Personal Coverage Form at the end of this application.
Dependent’s address, if different from employee – please indicate which dependent(s) this applies to:
Enrolling Spouse/Domestic
HMO Personal Physician
Dental provider
Partner Information
Enroll In
* HMO Plans Only
*Dental HMO only
* Please check
Doctor’s name:
Dental provider name:
Spouse Domestic Partner
all that apply:
Male Female
First _________________________________
First _________________________________
Medical
Date of marriage/domestic
Dental
Last _________________________________
Last _________________________________
partnership _______________
Vision
Provider number ____________________
First ___________________________ MI __
Life
Dental provider number:
IPA/MG number _____________________
Last _________________________________
_____________________________________
Social Security ______________________
Existing patient? Yes No
Existing patient? Yes No
Date of birth (mm/dd/yyyy):
_______________
Enrolling Dependent
HMO Personal Physician
Dental provider
Children Information
Enroll In
* HMO Plans Only
*Dental HMO only
* Please check
Doctor’s name:
Dental provider name:
Male Female
all that apply:
First ___________________________ MI __
First _________________________________
First _________________________________
Medical
Dental
Last _________________________________
Last _________________________________
Last _________________________________
Vision
Social Security ______________________
Provider number ____________________
Life
Dental provider number:
IPA/MG number _____________________
Date of birth (mm/dd/yyyy):
_____________________________________
_______________
Existing patient? Yes No
Existing patient? Yes No
* Please check
Doctor’s name:
Dental provider name:
Male Female
all that apply:
First _________________________________
First _________________________________
First ___________________________ MI __
Medical
Dental
Last _________________________________
Last _________________________________
Last _________________________________
Vision
Provider number ____________________
Social Security ______________________
Life
Dental provider number:
Date of birth (mm/dd/yyyy):
IPA/MG number _____________________
_____________________________________
_______________
Existing patient? Yes No
Existing patient? Yes No
* Please check
Male Female
Doctor’s name:
Dental provider name:
all that apply:
First _________________________________
First _________________________________
First ___________________________ MI __
Medical
Dental
Last _________________________________
Last _________________________________
Last _________________________________
Vision
Provider number ____________________
Social Security ______________________
Life
Dental provider number:
IPA/MG number _____________________
Date of birth (mm/dd/yyyy):
_____________________________________
_______________
Existing patient? Yes No
Existing patient? Yes No
* Please check
Doctor’s name:
Dental provider name:
Male Female
all that apply:
First ___________________________ MI __
First _________________________________
First _________________________________
Medical
Dental
Last _________________________________
Last _________________________________
Last _________________________________
Vision
Social Security ______________________
Provider number ____________________
Life
Dental provider number:
IPA/MG number _____________________
Date of birth (mm/dd/yyyy):
_____________________________________
_______________
Existing patient? Yes No
Existing patient? Yes No
Please be sure to return all pages of this form as the last page contains your signature which is necessary to process these changes.
Missing information may delay processing. Fax requests to (209) 367-6475.
C12914 (8/11)
Employee Application
2 of 4
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