Form Gef040 - Group Enrollment printable pdf download

GROUP ENROLLMENT FORM

PO Box 22999, Rochester, New York 14692

A nonprofit independent licensee of the BlueCross BlueShield Association

Instructions on Back. All Dates = mm/dd/yy

 Check if name change

 Check if new address

 CHECK DESIRED ACTION

 CHECK DESIRED COVERAGE - Select One Product Option

 CHECK PERSON(S) COVERED

Classic Blue:

 Excellus BlueEPO (BE)

Self, Spouse &

Self &

Self

 HMOBlue 25 (MZ)

 Add Subscriber (AA)

Child(ren)

Spouse

 Regionwide (KC)

 BlueEPO Balance (UE)

 HMOBlue 30 (MW)

___ / ___ / ___

Date of Hire/Event

( A )

( B )

( C )

( D )

 BCBS and Enhanced Benefits (KC)

Blue Healthy Choices A:

 Secure Comp (SC)

___ / ___ / ___

 Classic Blue Secure (KS)

Coverage Eff Date

 Fit & Healthy (FH)

 Senior Ins. High Option (SH)



MEDICAL

 Excellus BluePPO (BP)

 Healthy Family (FM)

 BluePoint 2 (SF)

 Add Dependent (AB)

 Excellus BluePPO/HSA (HF)



DENTAL

Blue Healthy Choices B:

 BCBS Traditional (TR)

___ / ___ / ___

 BluePPO Savings Account Plan

Date of Event

Please circle one of the following:

 Fit & Healthy (FB)

 BCBS Comprehensive (CO)

(DC)

___ / ___ / ___

Coverage Eff Date

 Healthy Family (FC)

 Traditional Rx only (RX)

 BluePreferred PPO (PN)

Platinum 1

 CHECK DESIRED COVERAGE

Platinum 2

 Change Coverage (AC)

 Dental (DE)

 Dental Blue Classic (DI)

 Dental Blue Options (DJ)

___ / ___ / ___

Coverage Eff Date

SUBSCRIBER INFORMATION - Must be completed

 Check if Married:

 Yes  No

Date of marriage: ____ /____ / ____

 Transfer to COBRA (AD)

Social Security # ________ - _______- _____________

Sex:  M  F

Birthdate: ____ / ____ / ____

 (S)ubscriber  (D)isabled

 (M) Dependent

Last Name

First

Street

___ / ___ / ___

Date of Event

City

State

Zip

 Cancel Subscriber (S)

Day Phone: ____________________________

E-mail Address: ______________________________

 Cancel Dependent (M)

Do you have Medicare?  Yes  No

If yes, indicate reason:  Age  Disabled  ESRD

 (M)edical

Medicare Claim #:

Medicare Part A Eff Date:

Medicare Part B Eff Date:

 (D)ental

Employment status:  Active  Retired, Provide Retirement date ____ / ____ / ____

Reason Code

(See back)

Blue Point 2 and HMOBlue Member must select a Primary Care Physician (PCP)

___ / ___ / ___

Cancellation Date

Primary Care Physician (Last)____________________ _ (First)_________________ Current patient?  Y N

If Reason Code SD or DM, indicate

BluePoint 2 members may select a OB/GYN provider

OB/GYN Physician (Last)_________________________ (First)_________________ Current patient?  Y N

___ / ___ / ___

Date of Death

FAMILY MEMBER INFORMATION  Check relationship and indicate dependent name or indicate dependent name and birthdate to be cancelled.

 (S)pouse  (D)ependent  (H) Disabled Dependent

 Other __________________

Primary Care Physician

Current patient? Y N

 Student(T)  Full-time

 Part-time # of Credit Hours:______________

Last ____________________________________ First _________________

Graduation Date: _____________________

OB/GYN Provider

Current patient? Y N

School Name:

Last____________________________________ First__________________

Social Security # ________ - _______- ____________

Enrolled with Medicare? Y  N If yes, indicate reason:  Age  Disabled  ESRD

____ / ____ / ____

Sex:  M  F Birthdate:

Medicare Claim #:

Last Name (if different):________________________ First Name:__________________

Medicare Part A Eff Date:

Medicare Part B Eff Date:

 (S)pouse  (D)ependent  (H) Disabled Dependent

 Other __________________

Primary Care Physician

Current patient? Y N

 Student(T)  Full-time

 Part-time Graduation Date: _____________________

Last ____________________________________ First _________________

School Name:

OB/GYN Provider

Current patient? Y N

Social Security # ________ - _______- ____________

Last____________________________________ First__________________

____ / ____ / ____

Sex:  M  F Birthdate:

Enrolled with Medicare? Y  N If yes, indicate reason:  Age  Disabled  ESRD

Last Name (if different):________________________ First Name:__________________

Medicare Claim #:

Medicare Part A Eff Date:

Medicare Part B Eff Date:

 (S)pouse  (D)ependent  (H) Disabled Dependent

 Other __________________

Primary Care Physician

Current patient? Y N

 Student(T)

 Full-time

 Part-time

Graduation Date: _____________________

Last ____________________________________ First _________________

School Name:

_____________

OB/GYN Provider

Current patient? Y N

Social Security # ________ - _______- ____________

Last____________________________________ First__________________

____ / ____ / ____

Sex:  M  F Birthdate:

Enrolled with Medicare? Y  N If yes, indicate reason:  Age  Disabled  ESRD

Last Name (if different):________________________ First Name:__________________

Medicare Claim #:

Medicare Part A Eff Date:

Medicare Part B Eff Date:

OTHER COVERAGE INFORMATION - Must be completed. You may be contacted for additional information. In addition, please provide a copy of your "Certificate of

Coverage" from your former health insurance carrier or employer. Have you or any member of your family been enrolled in any other insurance policy in the last 63 days

(including Dental, Medicare or Medicaid)?  Yes  No Check all that apply:  Medical  Dental  Vision

 Prescription Drug

___ / ___ / ___

Are you keeping this coverage? Yes No -- If No, indicate cancel date

: ___ / ___ / ____

Did this insurance cover

Policyholder’s Name_______________________________________

Effective Date

Insured  Insured and Family

 Check previous insurance company from list below and indicate ID #:_______________________________________

 (B) Excellus BlueCross BlueShield

 (O) Other - BlueCross BlueShield Plan. Indicate Plan Name: _____________________________________________________________________________________________

 (C) Other Carrier - Indicate Plan Name:

RELEASE - You must sign and date this form to be eligible for insurance.

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim

containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a

fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed $5,000 and the stated value of the claim for each

such violation. I have thoroughly read, understand and agree to comply with the terms of the Release on the back.

Subscriber Signature ______________________________________________________________Date_________________________________

EMPLOYER INFORMATION (Must be completed by Group Representative) Shaded areas are optional.

Was the employee subject to a waiting period before enrolling in your employer health plan?  Yes  No

If yes, what was the start date ____/____/____ and end date ____/____/____

Coverage

Group/Sub Group #

Chk Digit

Pkg #

Employer Name:

Medical

Employee Status:  (A) Active  (A) Full Time  (A) Part-time - # of Hours________  (A) Cobra  (A)