Form Gef040 - Group Enrollment (Page 2 of 2) in pdf

Instructions for completing the Group Enrollment Form

DESIRED ACTION - Check the appropriate action and indicate the Date(s) in the space provided. An Event Date is the date of a specific occurrence, due to

change in status, marriage, divorce, birth or adoption, group's anniversary date, or rate change. Your request must be received within 30 days of the Event

Date. Please see your Group Representative for events that fall outside the 30-day period. If New Add Subscriber, Add Dependent or Change Coverage,

you must also check Desired Coverage and Persons covered, and Family Member Information section.

Cancel Request

To process a Subscriber or Member Cancellation, please use the Membership Cancellation Worksheet - OR -

To Cancel an Employee/Subscriber using the

To Cancel a Dependent using the

Group Enrollment Form:



Check Cancel Subscriber (S) Box

Check Cancel Dependent (M) box



Check Products to be cancelled (Medical, Dental)



Indicate Reason Code in space provided (See codes below)

Indicate Reason Code in space provided (see codes below)



Indicate Cancellation Date in space provided



Complete Subscriber Information



Complete Member Name and Member Birthdate

Cancel Subscriber Reasons

Cancel Dependent Reasons

CE – Cobra End Date (29)

CB – COBRA Begin Date

LE – Left Employer/No Longer(11)

MA – Marriage (25)

CP – Commercial (09)

MR – Subscriber Request (02)

SD – Subscriber Deceased (05)

OA – Dependent Over Age (20)

SB – Spouse's Excellus BCBS

DV – Divorce (25)

SR – Subscriber Request (02)

DM – Deceased (05)

MC – Medicaid

MX – Medicare (03)

CB – Cobra Begin Date

MS – Ineligible Student (28)

MX – Medicare (03)

CD – Cobra Disabled Date

If the only change is one of the following, please call Customer Service at the telephone number indicated on your identification card. A Group Enrollment Form is not required.

 Address

 Birthdate

 PCP or OB/GYN

DESIRED COVERAGE

All products may not be applicable to your employer group. Please check with your Group Representative.

SUBSCRIBER

If you or your dependents are Medicare eligible, complete the Medicare Eligible-Group Enrollment Form. If you are disabled, see your

Group Representative to determine eligibility for OBRA. If eligible, complete the appropriate form.

FAMILY MEMBER QUALIFIED GUIDELINES:

If there are more than three members please use an additional form.



A legal spouse (an ex-spouse is not a qualified member as of the divorce date)

 Must be under the dependent and student age for your employer group

- Unmarried child, natural, adopted or stepchild

- A full-time student (indicate under Relationship)

- Chiefly dependent upon you for support

 Other: The following dependents have additional eligibility requirements.

Dependents pending adoption, grandchild dependent*, dependents for whom employee/subscriber has legal custody or legal guardianship, or a

dependent who is claimed on subscriber’s current federal income tax return, or a disabled dependent who is over the dependent age for your employer

group. Please contact Customer Service for the appropriate form.

*if supporting documentation is attached.

RELEASE



I am applying to enroll myself and my eligible dependents, if any, under the medical and/or dental contract.

 In the event that a premium contribution is required of me, I agree to pay the premium amounts applicable to the contract

under which I am covered. I authorize my employer to deduct from my payroll such applicable amounts and to remit them

to Excellus BlueCross BlueShield.

 If this application is made on behalf of a minor, the responsible party must complete the application.

 By accepting this contract, I grant permission to Excellus BlueCross BlueShield to submit charges to and/or recover

payment from any other insurance carrier acting as my primary insurer.

 I authorize Excellus BlueCross BlueShield to request and receive medical or dental information regarding me or my

covered dependents from my healthcare practitioner or healthcare institution either orally or in writing and to use this

information for providing coverage. Providing coverage includes: processing claims, reviewing grievances or complaints

involving care and quality assurance reviews of care, whether based on a specific complaint or a routine audit of randomly

selected cases. In the use of data for these purposes, we may transmit personal information to third parties with which we

contract, including pharmacy benefit managers, disease management vendors or surveyors.

 I hereby represent that all information furnished by me hereon is true and complete to the best of my knowledge.

The certificate or contract for which application is being made may impose a waiting period of up to twelve (12) months for

preexisting conditions, subject to the provisions of applicable law including creditable coverage requirements. The

certificate or contract document will describe any applicable waiting periods.

EMPLOYER INFORMATION

This section to be completed by the Employer Group Representative.

Complete only the coverage section (Medical, Dental) that is applicable to the employee's request.

If you have any questions, please contact Customer Service

Traditional or Comprehensive: 1-800-765-5226

HMO or Point of Service: 1-800-722-7884

PPO: 1-877-381-8659

Membership Inquiries:

1-800-765-5224

Form Gef040 - Group Enrollment Page 2

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