Enrollment Application Change Form - Blue Cross And Blue Shield Page 3
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1
2
3
4ENROLLMENT PPLIC TION/CH NGE FORM
Group No.
Section No.
Dept No.
Social Security No.
Group No.
Section No.
Dept No.
Category
SECTION 1 — ENROLLMENT EVENTS
P
– I
,
S
2, 8,
9
LE SE CHECK LL TH T PPLY
F YOU RE DECLINING COVER GE
COMPLETE
ECTIONS
ND
ONLY
n
n
n
n
n
n
New Enrollee
Add Dependent
Open Enrollment
Other Change(s)
Cancel Enrollee
Cancel Dependent
n
n
List names of those cancelling in Section 4 below
Are you applying as a result of a Special Enrollment Event?
No
Yes, Event Date: ____ / ____ / ____
Event:
n
Divorce
n
Death
n
n
Event:
Marriage
Birth, Adoption, Suit for Adoption
n
Terminated Employment
n
Court Order (see instructions)
n
Other
n
Loss of Other Coverage
Indicate Event Date: ____ / ____ / ____
n
Other (Explain)
n
n
Cancel Coverage:
Health
Dental
Effective Date of Benefits : ____ / ____ / ____
NOTE: Declination of Coverage (Complete Sections 2, 8 & 9)
SECTION 2 — PLE SE TELL US BOUT YOURSELF
Last Name
First Name
MI (opt)
Suffix
Birth Date
Social Security No.
(MM/DD/YYYY)
–
–
Mailing Address - Street - Apt No.
City
State
Zip
n
E-Mail Address
Male
Home/Cell Phone No.
n
Female
Name of Employer
Job Title
Business Phone No.
Employment Date
On average, how many hours do
(MM/DD/YYYY)
you work per week? (Required)
Eligibility Status:
n
Active Employee
n
Retired Employee - Date of Retirement:
n
n
COBRA Continuation
State Six-Month Continuation of Group Coverage (insured plans only)
SECTION 3 — SELECT YOUR COVER GE
P
C
T
LE SE
HECK
LL
H T
PPLY
SECTION 3 — SELECT YOUR COVER GE
Small Group Plans (2-50 employees)
Health Coverage (select one)
Who is covered? (select one)
BlueCare Dental Coverage
Who is covered? (select one)
n
n
n
n
Blue PPO
Employee Only
Yes
Employee Only
n
n
n
Blue EPO
Employee /Spouse
No
n
Employee /Spouse
n
BlueAdvantage HMO
n
n
SM*
Employee /Child(ren)
Employee /Child(ren)
n
n
n
Blue HMO
Family
Family
n
n
7-character Plan # (required)
I am not applying for Health coverage
I am not applying for Dental coverage
*Plan is available for groups located in and members residing in the following counties:
Bernalillo, Sandoval, Torrance, Valencia
Large Group Plans (51 or more employees)
Health Coverage (select one)
Who is covered? (select one)
Dental Coverage
Who is covered? (select one)
n
n
BlueEdge
HCA
Blue PPO Evolution
n
n
n
SM
SM
Employee Only
Yes
Employee Only
n
n
n
n
n
BlueEdge
SM
HSA
HMO Blue
®
Alternatives
Employee /Spouse
No
Employee /Spouse
n
n
n
BlueEdge
SM
HSA 100
Employee /Child
Plan # (required)
Employee /Child
n
BlueNet
EPO
n
Employee /Child(ren)
n
Employee /Child(ren)
®
n
BlueNet
“H” EPO
n
n
®
Family
Family
n
n
I am not applying for Health coverage
I am not applying for Dental coverage
n
n
n
n
COBRA
BlueSecure
Six-Month Continuation
Group Secondary to Medicare
Applicant’s Primary Language:
S
PCP
HMO
SECTION 4 — COVER GE OPTIONS
ELECT
FOR
ONLY
Employee/Enrollee’s Name
PCP Name
PCP No.
New Patient?
n
n
Y
N
n
n
Dependent’s Name
Husband
Wife
Dependent’s PCP Name
PCP No.
New Patient?
n
n
Y
N
Dependent’s Social Security No.
Birth Date
Address (if different) - No. And Street Address
City
State
Zip
(MM/DD/YYYY)
–
–
Dependent’s Social Security No.
Dependent’s PCP Name
PCP No.
New Patient?
Dependent’s Name: ______________________________________
n
n
–
–
Y
N
n
n
n
Son
Daughter
Other Eligible Dependent ____________ __
Birth Date
Home Address, if different — No. and Street Name/City/State/Zip
Is this dependent a natural child, stepchild,
If not your natural child, stepchild, eligible foster child or
(MM/DD/YYYY)
eligible foster child or adopted child?
adopted child, are you (or your spouse) financially responsible for this
n
n
Y
N
n
n
dependent?
Y
N
If no, attach copy of court order or decree.
Dependent’s Social Security No.
Dependent’s PCP Name
PCP No.
New Patient?
Dependent’s Name: ______________________________________
n
n
–
–
Y
N
n
n
n
Son
Daughter
Other Eligible Dependent ____________ __
Birth Date
Home Address, if different — No. and Street Name/City/State/Zip
Is this dependent a natural child, stepchild,
If not your natural child, stepchild, eligible foster child or
(MM/DD/YYYY)
eligible foster child or adopted child?
adopted child, are you (or your spouse) financially responsible for this
n
Y
n
N
n
n
dependent?
Y
N
If no, attach copy of court order or decree.
Dependent’s Social Security No.
Dependent’s PCP Name
PCP No.
New Patient?
Dependent’s Name: ______________________________________
n
n
–
–
Y
N
n
n
n
Son
Daughter
Other Eligible Dependent ____________ __
Birth Date
Home Address, if different — No. and Street Name/City/State/Zip
Is this dependent a natural child, stepchild,
If not your natural child, stepchild, eligible foster child or
(MM/DD/YYYY)
eligible foster child or adopted child?
adopted child, are you (or your spouse) financially responsible for this
n
n
Y
N
n
n
dependent?
Y
N
If no, attach copy of court order or decree.
81809.0814
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