Federal Dentalblue Enrollment Form (Page 3 of 4) in pdf

COVERED DEPENDENTS

LAST NAME*

FIRST NAME*

MIDDLE NAME

SUFFIX (JUNIOR, SENIOR)

SOCIAL SECURITY NUMBER*

DATE OF BIRTH (MM/DD/YYYY)*

RELATIONSHIP

GENDER

CHILD

OTHER_________________________________

MALE

FEMALE

LAST NAME*

FIRST NAME*

MIDDLE NAME

SUFFIX (JUNIOR, SENIOR)

SOCIAL SECURITY NUMBER*

DATE OF BIRTH (MM/DD/YYYY)*

RELATIONSHIP

GENDER

CHILD

OTHER_________________________________

MALE

FEMALE

If you need to list more dependents, please attach an additional sheet.

ENROLLMENT PERIOD

As long as you remain eligible for enrollment in Alabama Federal DentalBlue, your enrollment period is for the entire calendar year. The Alabama Federal

DentalBlue beneﬁ ts are based upon year-long premiums. (For federal employees hired during the calendar year, who transfer in to Alabama from another

state within the same federal agency, or who elect coverage due to termination of existing coverage, the enrollment period and total premium liability are

determined based on the effective date of enrollment.) If you cancel your Alabama Federal DentalBlue coverage, you will not be able to re-enroll during

the next three Open Seasons except if you return to full-time civilian employment from active military duty.

PAYMENT INFORMATION

You can pay your monthly premium by personal check with coupon book, E-Check Electronic Funds Transfer or Automatic Bank Card using a credit or

debit card. Please select a payment option below. If you do not select a payment option, you will receive a coupon book and pay by personal check.

Personal Check with Coupon Book

E-Check Electronic Funds Transfer - please also complete and attach the enclosed Authorization Agreement,

stock number CAD – 56, with a blank voided check.

Automatic Bank Card with credit or debit card - please also complete and attach the enclosed Authorization Agreement,

stock number CAD – 56.

I UNDERSTAND

These beneﬁ ts are neither offered nor guaranteed under the FEHB Program, but are made available to all enrollees and dependents who are members of

the Service Beneﬁ t Plan and live in the service area of Blue Cross and Blue Shieldof Alabama. If I choose the FEHB Basic Option, I will be enrolled in the

Alabama Federal DentalBlue Basic Option. If I choose the FEHB Standard Option, I will be enrolled in the Alabama Federal DentalBlue Standard Option.

The cost of these beneﬁ ts is not included in the FEHB premium, and charges for these services do not count toward any FEHB deductibles or catastrophic

protection beneﬁ ts.These beneﬁ ts are not subject to the FEHB disputed claims procedures.

I acknowledge and agree:

that each response in this application has been entered by me or at

that coverage shall become effective only after this application is

approved by the Plan and shall be only as stated in the contract

my direction and may be used by the plan to determine eligibility of

issued by the Plan; and

me and any family member for this coverage and that, if I have

misstated or omitted any material information, the Plan may declare

that any health care provider having information or records pertaining

such coverage null and void from its issuance; and

to me or any covered family member is authorized and directed to