Enrollment Application Change Form - Blue Cross And Blue Shield (Page 2 of 4) in pdf

ENROLLMENT PPLIC TION / CH NGE FORM INSTRUCTIONS

PLE SE RE D THOROUGHLY BEFORE COMPLETING ENROLLMENT PPLIC TION / CH NGE FORM

Use a black or blue ballpoint pen only. Print neatly. Do not abbreviate.

SECTION 1

Check all the boxes that apply to indicate if you are a new enrollee or if you are requesting a change to your coverage. Indicate the event and date,

if applicable. Complete the additional sections that correspond to your selection.

New Enrollee: Complete all Sections where applicable.

Add Dependent: Complete all Sections where applicable.

• If you are adding or enrolling a dependent due to court order, you must submit a copy of the court order or decree.

• If you are applying for coverage for a disabled dependent over the age limit of your employer's plan, please provide the additional information

requested in Section 5. dditional documentation may be required as addressed in that section.

Cancel Enrollee: Complete Sections 1, 2, 4, and 9. In Section 4 include name, social security number, and date of birth of individual(s) cancelling.

Cancel Dependent: Complete Sections 1, 2, 4, and 9. In Section 4 include name and date of birth of individual(s) cancelling.

Declining Coverage: Complete Sections 2, and 9.

SECTIONS 2 & 3

If you work for an employer with 2-50 employees, please list the seven-character plan ID for your selected benefit design (example: B817PPO) in the

Plan # field. If you are unsure of your group size or do not know your plan ID, please ask for guidance from your employer.

SECTION 4

Complete all areas that apply to you and each dependent.

For HMO only: Those applying for HMO coverage should select a PCP for each individual to be covered. List the name of the physician and the

provider number from the provider directory or Provider Finder at www. c . Be sure to check the appropriate box for a new patient.

Change Primary Care Physician (PCP): In Section 1, check the “Other Change(s)” box, then complete sections 2, 4, and 9. In Section 4, please

include enrollee's or dependent’s name, social security number, date of birth, and name and number of the new PCP.

Change Address / Name: In Section 1, check the “Other Change(s)” box, then complete Sections 2 and 9.

SECTION 5

Complete this section if you are applying for coverage for a disabled dependent child over the dependent child age limit of your employer’s plan.

disabled dependent must be certified by medical underwriting and a completed Dependent Child’s Statement of Disability form must be submitted with

this enrollment application.

SECTION 6

Complete this section if you or any dependent have group or individual health and/or dental coverage that will not be cancelled when the coverage

under this application becomes effective.

Complete this section if you or any of your dependents are covered by Medicare.

SECTION 7

SECTION 8

Complete this section if you are declining health coverage for yourself and your dependents. Anyone declining coverage for any reason should complete

Section 8, not just those declining because of other coverage.

IMPORTANT NOTICE – DECLINATION OF HEALTH COVERAGE

If you are declining enrollment for yourself or your dependents (including your spouse) because of other health care coverage,

you may, in the future, be able to enroll yourself or your dependents in the plan if you request enrollment within 31 days after

your other coverage ends. In addition, if you have a new dependent as a result of a marriage, birth, adoption, placement for

adoption, or placement in your home as a foster child, you may be able to enroll yourself and your dependents if you request

enrollment within 31 days after the marriage, birth, adoption, or placement for adoption, or placement of an eligible foster

child in your home.

IMPORTANT NOTICE - PEDIATRIC DENTAL

This policy does not include pediatric dental services as required under the federal Patient Protection and ffordable Care ct.

This coverage is available in the insurance market and can be purchased as a stand-alone product. Please contact your

insurance carrier, agent or the New Mexico Health Insurance Exchange - if you wish to purchase pediatric dental

coverage or a stand-alone dental insurance product.

SECTION 9

Sign your name and date the enrollment application if you agree to the conditions set forth in this section. Your enrollment application should be submitted

to your employer, who will then submit your form to: BCBSNM Membership Dept. • P. O. Box 27630 • Albuquerque, NM 87125-7630 or via

fax at 505-837-8950

Changes in state or federal law or regulations, or interpretations thereof, may change the terms and conditions of coverage.

Forms referenced above may be obtained by accessing the BCBSNM website at www. c , from your Account

Representative, or from your employer. If you have any questions, please contact your Account Representative.

81809.0814

Enrollment Application Change Form - Blue Cross And Blue Shield Page 2

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