Enrollment Change Request Form - Horizon Blue Cross
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ENROLLMENT/CHANGE REQUEST
P.O. Box 1710
Newark, NJ 07101-1938
Group Information -
To Be Completed by Employer
Horizon BCBSNJ Dental Programs
1-800-4DENTAL
Group Name
Group Number
Subgroup Number
A. Type of Activity
Print clearly.
- To Be Completed by Employer Refer to instructions on back before completing this form.
1. Enrollment
4. Continuation of Coverage, i.e., COBRA, State,
2. Change -
3. Remove or Terminate -
Date of Event
Reason
Check all that apply.
Check all that apply.
Total Disability
Effective Date
Reason
New Subscriber
2.
Add Spouse
2.
2.
Remove Spouse/Domestic Partner/
Not all options are available. Contact Employer for available options.
Domestic Partner
Effective Date
Coverage For:
Employee
Dependents
2.
Civil Union Partner*
____/____/____ ____________
Civil Union Partner
___/___/___ _____________
Length of Continuation:
18 mos
29 mos*
36 mos
2.
Add Dependent Child
___/___/___ _____________
______/______/______
2.
Remove Dependent Child*
____/____/____ ____________
Total Disability
2.
Name Change
___/___/___ _____________
Date of Hire
2.
Employee Withdrawal/Termination ____/____/____ ___________
Date of Loss of Coverage: ____/____/____
2.
Change Plan
___/___/___ _____________
Note: Employee must be enrolled for spouse/domestic partner/civil union partner/
2.
Other
___/___/___ _____________
____/____/____
Date of Qualifying Event:
______/______/______
Note:
dependent(s) to have coverage.
*Attach proof of disability
2.
Add/Change Dentist Office ID
*Please complete Add/Change/Remove and Name columns in Section D.
B. Employee Information -
C. Plan Option -
Complete Sections B - G
Your selection must be offered by your employer.
Social Security Number
L
a
t s
N
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m
, e
F
r i
t s
N
a
m
, e
M
. I .
H
o
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e
(
)
Horizon BCBSNJ
Horizon Healthcare Dental
Contract Type
Home Address
Apt. No. City, State
ZIP Code
Horizon Dental Traditional
*Horizon Dental Choice
S - Single
F - Family
Work Telephone
Horizon Dental Option
*Horizon TotalCare Dental
2 Adults
Employer Name
(
)
Horizon Dental PPO
P/C - Parent & Child
Work Address
City, State
ZIP Code
Horizon Dental PPO Access
Date of Employment
Hours Worked
*Please select Dentist Office ID Number-Section D
D. Individuals Covered -
List individuals for whom you are adding/changing/removing coverage. Attach sheet to list additional children. Attach proof if full-time college student. Attach proof of disability.
Other Dental
Dentist Office
Current
Previous
(A)dd
Sex
Birthdate
NPI
Coverage
ID Number
(C)hange
Last Name, First Name, M.I.
Social Security Number
Patient
Coverage
Number
M
F
(R)emove
MM
DD
YYYY
(if applicable)
Check if Yes
Check if Yes
Check if Yes
Employee
/
/
Spouse
/
/
Domestic Partner
/
/
Civil Union Partner
/
/
Child
/
/
Child
/
/
Child
/
/
F. Dependent Information
E. Other/Previous Insurance
Is your Spouse/Domestic Partner/Civil Union Partner Employed?
Yes
No If “Yes,” give name & address of spouse’s/
Does any dependent listed in Section D live at a different address than the Employee?
Yes
No If “Yes,” who and at what address?
Domestic Partner’s/Civil Union Partner’s employer.
Explain the circumstances.
If “Yes” to Other Dental Coverage (Section D), give name & policy number of insurance carrier, HMO, or other source.
If any dependent’s last name differs from yours, explain the circumstances.
If “Yes” to previous coverage, identify name(s) of persons, give effective date and date coverage terminated, name of previous
carrier and plan number and submit a copy of the Certificate of Credible Coverage issued by the previous carrier, if available.
G. Employee Signature
If you have any questions concerning the benefits and services provided by or excluded under this contract, contact a
H. Employer Verification -
benefits representative at your company before signing this form.
To Be Completed by Employer
I represent that all the information supplied in this enrollment/change
Employee Signature - Required
Employer Signature - Required
request form is true and complete. I hereby agree to the conditions of
X
X
enrollment on the reverse side of the employee copy of this enrollment/
Date
E-Mail Address
Title
Date
change request. I authorize deductions from my earnings for any
required contribution.
/
/
/
/
Employee copy may be used as a temporary ID card for 30 days from the effective date if authorized by employer. Coverage must be verified with Horizon BCBSNJ Dental Programs prior to visiting a specialist or admission to a hospital.
Services and products may be provided by Horizon Blue Cross Blue Shield of New Jersey or Horizon Healthcare Dental, Inc., each of which is an independent licensee of the Blue Cross and Blue Shield Association. Horizon Healthcare Dental Inc., is a subsidiary of Horizon Blue Cross Blue Shield of New Jersey.
You may complete the required fields below online and then save or print a copy for submission. To save a completed copy to your computer,
2149 (W0208)
NJ-HINT
choose File > Save As to rename the file and save the form with your information to your computer.
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