Group Dependent Addendum printable pdf download

Group Dependent Addendum

Please complete the following for additional dependants and attach

it to the Group Member Application.

Employer group name________________________________

Group number___________________ Dept. number______

Employee name______________________________________

Social security number________-________-________

______-______-_______

Phone number_________-_________-____________

Effective date

Dependent Information

Dependent #6

Last name

First name

__ M.I.

Suffix

Relationship

c Son c Daughter

Coverage applied for: c Medical c Dental

c Vision

Date of birth (mm/dd/yyyy) ___ / ___ / ______

Social security number

________-________-________

Primary care physician (PCP) name, address

_____________________________________________________________

______________________________________________________________________________________________________

Is this dependent a current patient of the PCP listed above? c Yes c No

Dependent #7

Last name

First name

__ M.I.

Suffix

Relationship

c Son c Daughter

Coverage applied for: c Medical c Dental

c Vision

Date of birth (mm/dd/yyyy) ___ / ___ / ______

Social security number

________-________-________

Primary care physician (PCP) name, address

_____________________________________________________________

______________________________________________________________________________________________________

Is this dependent a current patient of the PCP listed above? c Yes c No

Dependent #8

Last name

First name

__ M.I.

Suffix

Relationship

c Son c Daughter

Coverage applied for: c Medical c Dental

c Vision

Date of birth (mm/dd/yyyy) ___ / ___ / ______

Social security number

________-________-________

Primary care physician (PCP) name, address

_____________________________________________________________

______________________________________________________________________________________________________

Is this dependent a current patient of the PCP listed above? c Yes c No

Social Security number is required in order to comply with the reporting requirements of the Mandatory Insurance Reporting Law.

See

By choosing the VantageBlue Select plan, you must select a Primary Care Physician (PCP) and other healthcare providers (including hospitals, specialists, labs, and durable

medical equipment suppliers) from the VantageBlue Select network in order to get the lowest out-of-pocket healthcare costs (e.g., copayments and coinsurance). Providers in the

VantageBlue Select network can be found at or in the Find A Doctor tool on . If you do not seek services from a VantageBlue

Select network provider or receive a network referral you will be responsible for the applicable higher out-of-network cost sharing.

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Group DEP ADD (10/15)