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

Last Name:

Social Security No:

—

Group #

—

SECTION 5 — DIS BLED DEPENDENT

Name of Disabled Dependent

Nature of Disability

Name of Disabled Dependent

Nature of Disability

If disabled child is over the dependent age limit of your employer’s plan, please attach a completed Dependent Child’s Statement of Disability form.

SECTION 6 — OTHER COVER GE INFORM TION

Complete this section only if you or any of your dependents have other health and / or dental coverage that will not be cancelled when the coverage under this application

becomes effective. List names of each individual covered:

Type of Policy

Employee/Child

Group Coverage

Name and Address of Other Insurance Carrier

Effective Date

(MM/DD/YYYY)

Employee Only

Employee/Children

Yes

Employee/Spouse

Family

Name of Policyholder

Birth Date

Male

Relationship to Applicant

(MM/DD/YYYY)

Female

Self

Spouse

Dependent

Employer’s Name

Employment Date

Health Group No.

Health ID No.

Dental Group No.

Dental ID No.

(MM/DD/YYYY)

SECTION 7 — MEDIC RE COVER GE INFORM TION

Name of person covered:

Medicare A (Hospital) Effective Date: ________________

End Date: ________________

Medicare HIC No.

Medicare B (Medical) Effective Date: _________________

End Date: ________________

(From Medicare Card)

Medicare D (Drug) Effective Date: ___________________

End Date: ________________

Medicare D (Drug) Carrier: ______________________________________

Please indicate reason for Medicare Eligibility:

Entitled Age

Entitled Disability

End-Stage Renal Disease

Disability and Current Renal Disease

Name of person covered:

Medicare A (Hospital) Effective Date: ________________

End Date: ________________

Medicare HIC No.

Medicare B (Medical) Effective Date: _________________

End Date: ________________

(From Medicare Card)

Medicare D (Drug) Effective Date: ___________________

End Date: ________________

Medicare D (Drug) Carrier: ______________________________________

Please indicate reason for Medicare Eligibility:

Entitled Age

Entitled Disability

End-Stage Renal Disease

Disability and Current Renal Disease

SECTION 8 — DECLIN TION OF COVER GE

This is to certify the available coverage has been explained to me. I have been given the opportunity to apply for the coverage offered to me and my eligible dependents and have voluntarily elected to decline

the coverage as indicated below. If I desire to apply for coverage at a later date, I understand there may be a delay in the effective date of the coverage.

Name

Employee

Reason for Declining Health:

Other Group Health Coverage; Carrier: __________________________________

Indian Health Services

Medicare

Medicaid

Other Individual Health Coverage; Carrier: __________________________________

Other, Explain: ____________________________________ _

I am not enrolled in any Health insurance plan, but do not want this coverage.

Name

Employee

Reason for Declining Dental:

Other Group Dental Coverage

Medicaid

Indian Health Services

Individual Dental Coverage

Other, Explain:_____________________________________

I am not enrolled in any Dental insurance plan, but do not want this coverage.

Name

Spouse

Reason for Declining:

Other Group Health Coverage

Medicare

Medicaid

Indian Health Services

Other Individual Health Coverage

Other, Explain:_____________________________________

I am not enrolled in any Health insurance plan, but do not want this coverage.

Name

Child

Reason for Declining:

Other Group Health Coverage

Medicare

Medicaid

Indian Health Services

Other Individual Health Coverage

Other, Explain:_____________________________________

I am not enrolled in any Health insurance plan, but do not want this coverage.

Name

Child

Reason for Declining:

Other Group Health Coverage

Medicare

Medicaid

Indian Health Services

Other Individual Health Coverage

Other, Explain:_____________________________________

I am not enrolled in any Health insurance plan, but do not want this coverage.

SECTION 9 — COVER GE CONDITIONS

• I am an employee of the Employer named in this Enrollment Application. I am eligible to participate in the coverage(s) afforded by my Employer’s plan, which is either underwritten or

administered by Blue Cross and Blue Shield of New Mexico (BCBSNM). On behalf of myself and any dependents listed on this Enrollment Application, I apply for those coverage(s) for

which I am eligible. I state that the information given on this Enrollment Application is true and correct. I understand and agree that any intentional misrepresentation of a material fact

made by me will invalidate my coverage(s).

• Only those coverage(s) and amounts for which I am eligible will be available to me. I understand that if this Enrollment Application is accepted, the coverage(s) will become effective in

accordance with the provisions of the Contracts(s)/Plan(s).

• I agree that my Employer acts as my agent. I authorize necessary payroll deduction by my Employer, if any, to cover the cost of my coverage(s).

• I understand that this coverage(s) is subject to any future amendment. I also understand that all notices given to my Employer are applicable to me.

ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE

INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES.

Applicant’s Signature

Date

81809.0814