Fillable 2056801 232320.0919 IL Group Enrollment Template Member Application Form.indd

Fill Online, Printable, Fillable, Blank 2056801 232320.0919 IL Group Enrollment Template Member Application Form.indd Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

2056801 232320.0919 IL Group Enrollment Template Member Application Form.indd

On average this form takes 66 minutes to complete

The 2056801 232320.0919 IL Group Enrollment Template Member Application Form.indd form is 5 pages long and contains:

  • 1 signature
  • 193 check-boxes
  • 171 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Please read the instructions on the inside thoroughly before completing
this enrollment application/change form.
Group Enrollment Application
|
Change Form
Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
Life and Disability insurance is underwritten by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148. Dearborn Life Insurance Company is an independent Blue Cross
and Blue Shield licensee. BLUE CROSS,
®
BLUE SHIELD
®
and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of
independent Blue Cross and Blue Shield Plans.
232320.0919
232320.0919 1
ENROLLMENT APPLICATION/CHANGE FORM INSTRUCTIONS
PLEASE READ THOROUGHLY BEFORE COMPLETING ENROLLMENT APPLICATION
/
CHANGE FORM
Use a black or blue ballpoint pen only. Print neatly. Do not abbreviate.
SECTION 1
ENROLLMENT EVENTS
Check all the boxes that apply to indicate if you are a new enrollee or if you are requesting a change to your coverage. Indicate the event and date, if applicable. Complete the
additional sections that correspond to your selection.
New Enrollee: Complete all sections where applicable.
Add Dependent: Complete all sections where applicable.
• If you are applying for coverage for a disabled dependent over the age limit of your employer’s plan, please provide the additional information requested in Section 5.
Additional documentation may be required as addressed in that section.
• If your employer offers coverage for children and your children are eligible, your children are eligible for health and/or dental coverage up to the dependent limiting age
and may not be denied coverage due to marital, student or employment status before age 26 (check with your employer for additional details regarding eligibility
requirements). In addition, eligible military personnel may not be denied coverage before age 30 under Illinois law. If you are adding an eligible military personnel
dependent who is over the age limit of the employer’s plan, completion of a Defense Department Form (DD 214) is required in addition to this application.
Open Enrollment: The period of time offered on a regular basis during which you can elect to enroll in a specific group health insurance plan or make changes to your
current membership.
Special Enrollment Event: If you qualify, special enrollment is any change to your current membership such as marriage*, divorce**, adoption, suit for adoption or placement for
adoption, leave/layoff, moving out of the service area, etc. This change may occur outside of open enrollment.
Effective Date of Benefits: Field is mandatory and should reflect your requested date.
Completion of Other Eligibility Requirements: Check this box only if your employer has eligibility requirements that you have met/completed prior to enrollment, such as
measurement period or orientation period.
Cancel Enrollee/Cancel Dependent/Cancel Coverage: Complete Sections 1, 2, 4 (skip Section 4 if declining coverage), 8 and 9. In Section 4 include name, social security
number and date of birth of individual(s) canceling.
SECTION 2
YOUR INFORMATION
Complete this section with details about yourself even if you are declining coverage.
SECTION 3
YOUR COVERAGE
Complete all portions related to the coverages for which you are applying. Please list the seven character plan ID for your selected benefit design (example: S533PPO) in the
plan # field. If you are unsure of your group size or do not know your plan ID, please ask for guidance from your employer.
If you are enrolling for life or disability insurance enter the information requested. When listing the beneficiary, provide both the first and last name and the relationship to you.
List all beneficiaries that apply.
SECTION 4
COVERAGE OPTIONS
Complete all areas that apply to you and each dependent.
For HMO Plans Only:
• Those applying for HMO coverage are required to select a primary care physician/practitioner (PCP) for each covered individual. List the name of the physician/practitioner and
the provider number from the provider directory or Provider Finder
®
at bcbsil.com. Be sure to check the appropriate box for a new patient.
• If you selected HMO coverage, you must select a medical group/individual practice associations (IPAs) and a primary care physician (PCP) for each person to be covered.
You must also select a PCP within the selected medical group/IPA for each person to be covered. You may choose a different medical group/IPA for each person. Care
received from a woman’s principal health care provider (WPHCP) may be eligible for coverage without referrals from your PCP. However, your PCP and your WPHCP must
be affiliated with or employed by your medical group/IPA in order for each person to be eligible for coverage. Until we receive your selected medical group/IPA, you may not
be eligible and your claims may be denied. Be sure to enter the medical group/IPA number, name, PCP number and name.
• If you are adding an eligible military personnel dependent who is over the age limit of your employer’s plan, completion of a Defense Department Form 214 (DD 214) is
required in addition to this application.
Change Primary Care Physician/Practitioner: Complete Section 1 and check the “Other Change(s)” box; then, complete Sections 2, 3, 4 and 9. In Section 4, please include
enrollee’s or dependent’s name, social security number, date of birth, name and number of the new PCP and the name and number of the new IPA.
Change Address/Name: Complete Section 1 and check the “Other Change(s)” box; then, complete Sections 2 and 9.
SECTION 5
DISABLED DEPENDENT
A disabled dependent must be medically certified as disabled and dependent upon you or your spouse***/domestic partner in order to be considered for coverage if dependent
overage is part of your employer’s plan. The disabled dependent is required to be covered prior to age 26 to be eligible for coverage over the dependent child age limit of your
employer’s plan. A Disabled Dependent Authorization and Disabled Dependent Physician Certification document must be completed and submitted with this enrollment
application, if applicable.
SECTION 6
OTHER COVERAGE
Complete this section if you or any dependent have other group or individual health and/or dental coverage (if applicable) that will not be canceled when the coverage under this
application becomes effective.
SECTION 7
MEDICARE COVERAGE
Complete this section if you or any of your dependents are covered by Medicare. Enter the start and end dates for the coverage that applies. Your Medicare HIC number must be
listed (it can be found on your Medicare ID card). Check the reason for your Medicare coverage.
SECTION 8
DECLINATION OF
COVERAGE
Complete this section if you are declining health coverage for yourself and your dependents. Anyone declining coverage for any reason should complete Section 8, not just those
declining because of other coverage.
IMPORTANT NOTICE: If you are declining enrollment for yourself or your dependents (including your spouse) because of other health care coverage, you may, in the future, be
able to enroll yourself or your dependents in the plan if you request enrollment within 31 days after your other coverage ends. In addition, if you have a new dependent as a result
of a marriage, party to a civil union, birth, adoption, becoming a party in a suit for adoption, or placement of a foster child in your home, you may be able to enroll yourself and your
dependents if you request enrollment within 31 days after the marriage, birth, adoption, suit for adoption or placement for adoption, or placement of an eligible foster child in
your home.
SECTION 9
COVERAGE CONDITIONS
Sign your name and date the enrollment application if you agree to the conditions set forth in this section. Your enrollment application should be submitted to your employer’s
Enrollment Department, which will then submit your form to BCBSIL
.
As used on the application (unless indicated otherwise): These terms may be used in a different way in other documents.
* The term “marriage” includes legal marriage and the establishment of a civil union or domestic partnership (coverage subject to your employer’s plan).
** The term “divorce” includes legal divorce and the comparable termination of a civil union or domestic partnership (coverage subject to your employer’s plan).
*** The term “spouse” includes a legal spouse and a party to a civil union or domestic partnership (coverage subject to your employer’s plan).
Changes in state or federal law or regulations, or interpretations thereof, may change the terms and conditions of coverage.
If you are a current member and have questions, you may call the Customer Service number on the back of your
member ID card.
SECTION 1 — ENROLLMENT EVENTS
PLEASE CHECK ALL THAT APPLY – IF YOU ARE DECLINING COVERAGE, COMPLETE SECTIONS 2, 8 AND 9 ONLY
New Enrollee Add Dependent Open Enrollment Other Changes
Are you applying as a result of a Special Enrollment Event?
No Yes, Event Date: ____ / ____ / ____
Event: New Hire Marriage* Birth
Adoption, Placement for Adoption or Suit for Adoption (provide legal documents)
Court Order (provide court order or decree)
Loss of Other Coverage
Other (explain):
Effective Date of Benefits: ____ / ____ / ____ Completion of Other Eligibility Requirements
Cancel Enrollee Cancel Dependent
Cancel Coverage:
Health Dental
Term Life Dependent Life
Short-Term Disability Long-Term Disability
List names of those canceling in Section 4 below
Event:
Divorce** Death
Terminated Employment Other
Indicate Event Date: ____ / ____ / ____
SECTION 2 — PLEASE TELL US ABOUT YOURSELF COMPLETE EVEN IF DECLINING COVERAGE
Last Name First Name MI (opt) Suffix Birth Date (MM/DD/YYYY) Social Security
– –
Mailing Address - Street - Apt # City State ZIP code
Email Address
Male
Female
Home/Cell Phone #
Name of Employer Job Title Business Phone #
Employment Date (MM/DD/YYYY)
On average, how many
hours a week do you work?
(required)
Eligibility Status:
n Active Employee n Retired Employee - Date of Retirement: n COBRA Coverage Start Date Projected End Date
Illinois Continuation (insured plans only) Start Date Projected End Date
SECTION 3 — SELECT YOUR COVERAGE PLEASE CHECK ALL THAT APPLY
Small Group Plans (1-50 Employees)
Affordable Care Act Plans
PPO Other
Blue Choice Preferred PPO
SM
Blue Options
SM
Blue Precision HMO
SM
BlueCare Direct
SM
Plan # (required)
Grandfathered and Grandmothered/Transitional Plans
Blue Advantage Entrepreneur PPO
SM
Blue Advantage HMO
SM
Blue Choice Select PPO
SM
Blue Advantage HMO Value Choice
SM
BlueEdge Select HSA
SM
Community Participation Organization (CPO)
BlueEdge HSA
SM
CPO Value Choice
BlueEdge HCA Direct
SM
Other
PPO Value Choice Plan # (required)
Mid-Market and Large Group Standard Plans (51+ Employees)
Previous BCBSIL or HMO Membership
Mid-Market & Large Group Standard Plans 51+
PPO
Blue Choice Options
SM
BlueEdge Select HSA
SM
Blue Advantage HMO
SM
Blue Choice Select PPO
SM
Plan # (required)
Blue Advantage HMO Value Choice
SM
BlueEdge HSA
SM
Other
Group #:
Section #:
Identification #:
Large Group Custom Plans (151+ Employees)
Traditional Blue Advantage HMO
SM
w/HCA BlueEdge Select HSA
SM
PPO Blue Choice Options
SM
BlueEdge Select HCA Direct
SM
CPO Blue Choice Select PPO
SM
Vision
CPO Value Choice BlueEdge HCA
SM
Hearing
HMO Illinois
®
BlueEdge HSA
SM
Medicare Supplement
HMO Illinois
®
w/HCA BlueEdge HCA Direct
SM
Other
Blue Advantage HMO
SM
BlueEdge Select HCA
SM
Dental
BlueCare Dental PPO
SM
Employee and Party to a Civil Union or Domestic Partner Individual/Employee
BlueCare Dental HMO
SM
Gender: Male Female Employee/Children
Dental Group # (if different than Medical Group policy #) Employee/Spouse
Family
Primary Language:
Group Term Life, Accidental Death and Dismemberment (AD&D) and Disability Insurance
I am not applying for Group Term Life, AD&D or Disability Insurance coverage
Employee Occupation/Job Title: ___________________________ Wage Rate $__________________ per hour week month year
Group Basic Term Life and AD&D I do not apply I do apply Amount $___________________________
Group Dependents’ Life
I do not apply I do apply
Group Supplemental Life
I do not apply I do apply
Employee Election: $ Spouse Election: $ Child Election: $
Short-Term Disability I do not apply I do apply
Long-Term Disability I do not apply I do apply
Primary First Name Initial Last Name Relationship Birth Date
(MM/DD/YYYY) Social Security #
Beneficiary – –
Contingent First Name Initial Last Name Relationship Birth Date
(MM/DD/YYYY) Social Security #
Beneficiary – –
As used on the application (unless indicated otherwise): These terms may be used in a different way in other documents.
* The term “marriage” includes legal marriage and the establishment of a civil union or domestic partnership (coverage subject to your employer’s plan).
** The term “divorce” includes legal divorce and the comparable termination of a civil union or domestic partnership (coverage subject to your employer’s plan).
*** The term “spouse” includes a legal spouse and party to a civil union or domestic partnership (coverage subject to your employer’s plan).
Life and Disability insurance is underwritten by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148. Dearborn Life Insurance Company is an independent Blue Cross and Blue Shield licensee. BLUE CROSS,
®
BLUE SHIELD
®
and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
232320.0919 2
ENROLLMENT APPLICATION/CHANGE FORM
Group # Section # Social Security #
Account #
Category
232320.0919 3
SECTION 4 — COVERAGE OPTIONS
PLEASE COMPLETE ALL AREAS THAT APPLY
(If you are adding an eligible military personnel dependent who is over the age limit of your
employer’s plan, completion of a Defense Department Form 214 (DD 214) is required in
addition to this application.)
Employee/Enrollee’s Name PCP Name
PCP #
IPA Name
IPA #
WPHCP Name
WPHCP #
New Patient?
Y N
HMO OB/GYN Name (optional) HMO OB/GYN #
Dependent’s Name
Husband Wife
Domestic Partner Party to a Civil Union
Dependent’s PCP Name PCP # New Patient?
Y N
IPA Name
IPA #
WPHCP Name
WPHCP #
HMO OB/GYN Name (optional)
HMO OB/GYN #
Dependent’s Social Security #
– –
Birth Date (MM/DD/YYYY)
Home Address (if different) Street/City/State/ZIP code
Dependent’s Name
Son Daughter Other Eligible Dependent
Dependent’s PCP Name PCP # New Patient?
Y N
Birth Date
(MM/DD/YYYY)
Home Address (if different) Street/City/State/ZIP code
Is this dependent a natural child, stepchild, foster
child, adopted child or a child in suit for adoption?
Y N
If not your eligible natural child, stepchild, foster child, adopted
child or child in suit for adoption, are you (or your spouse)
responsible for this dependent?
Y N
Dependent’s Social Security #
– –
IPA Name
IPA #
HMO OB/GYN Name (optional)
HMO OB/GYN #
Dependent’s Name
Son Daughter Other Eligible Dependent
Dependent’s PCP Name PCP # New Patient?
Y N
Birth Date
(MM/DD/YYYY)
Home Address (if different) Street/City/State/ZIP code
Is this dependent a natural child, stepchild, foster
child, adopted child or a child in suit for adoption?
Y N
If not your eligible natural child, stepchild, foster child, adopted
child or child in suit for adoption, are you (or your spouse)
responsible for this dependent?
Y N
Dependent’s Social Security #
– –
IPA Name
IPA #
HMO OB/GYN Name (optional)
HMO OB/GYN #
Dependent’s Name
Son Daughter Other Eligible Dependent
Dependent’s PCP Name PCP # New Patient?
Y N
Birth Date
(MM/DD/YYYY)
Home Address (if different) Street/City/State/ZIP code
Is this dependent a natural child, stepchild, foster
child, adopted child or a child in suit for adoption?
Y N
If not your eligible natural child, stepchild, foster child, adopted
child or child in suit for adoption, are you (or your spouse)
responsible for this dependent?
Y N
Dependent’s Social Security #
– –
IPA Name
IPA #
HMO OB/GYN Name (optional)
HMO OB/GYN #
SECTION 5 — DISABLED DEPENDENT
PLEASE COMPLETE IF APPLICABLE
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 Disabled Dependent Certification and the Disabled Dependent Physician Certification document.
SECTION 6 — OTHER COVERAGE INFORMATION
PLEASE COMPLETE ALL AREAS THAT APPLY
Complete this section only if you or any of your dependents have other health and/or dental coverage that will not be canceled when the coverage under this
application becomes effective. List names of each individual covered:
Group Coverage
Y N
Individual Coverage
Y N
Name and Address of Other Insurance Carrier Effective Date
(MM/DD/YYYY)
Type of Policy
Employee Only Employee/Spouse
Employee/Child(ren) Family
Name of Policyholder Birth Date
(MM/DD/YYYY)
Male
male
Relationship to Applicant
Self Spouse Dependent
Employer’s Name
Employment Date
(MM/DD/YYYY)
Health Group # Health ID # Dental Group # Dental ID #
SECTION 7 — MEDICARE COVERAGE INFORMATION
PLEASE COMPLETE IF APPLICABLE
Name of person covered: Medicare A (Hospital) Effective Date: End Date: ________________
Medicare B (Medical) Effective Date: End Date: ________________
Medicare D (Drug) Effective Date: End Date: ________________
Medicare D (Drug) Carrier:
Medicare HIC #
(From Medicare Card)
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 B (Medical) Effective Date: End Date: ________________
Medicare D (Drug) Effective Date: End Date: ________________
Medicare D (Drug) Carrier:
Medicare HIC #
(From Medicare Card)
Please indicate reason for Medicare Eligibility:
Entitled Age Entitled Disability End-Stage Renal Disease Disability and Current Renal Disease
Last Name:
Social Security #:
Group #
Health care coverage is important for everyone.
We provide free communication aids and services for anyone with a disability or who needs language assistance.
We do not discriminate on the basis of race, color, national origin, sex, gender identity, age or disability.
To receive language or communication assistance free of charge, please call us at 855-710-6984.
If you believe we have failed to provide a service, or think we have discriminated in another way, contact us to file a grievance.
Office of Civil Rights Coordinator Phone: 855-664-7270 (voicemail)
300 E. Randolph St. TTY/TDD: 855-661-6965
35th Floor Fax: 855-661-6960
Chicago, Illinois 60601 Email: CivilRightsCoordinator@hcsc.net
You may file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, at:
U.S. Dept. of Health & Human Services Phone: 800-368-1019
200 Independence Avenue SW TTY/TDD: 800-537-7697
Room 509F, HHH Building 1019 Complaint Portal: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf
Washington, DC 20201 Complaint Forms: http://www.hhs.gov/ocr/office/file/index.html
232320.0919 bcbsil.com 4
SECTION 8 — DECLINATION OF COVERAGE
PLEASE COMPLETE IF YOU ARE DECLINING COVERAGE
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: __________________________________ 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 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 Other Individual Health Coverage
Other (explain)_____________________________________
I am not enrolled in any health insurance plan, but do not want this coverage
Name Dependent Reason for declining: Other Group Health Coverage Medicare Medicaid Other Individual Health Coverage
Other (explain)_____________________________________
I am not enrolled in any health insurance plan, but do not want this coverage
Name Dependent Reason for declining: Other Group Health Coverage Medicare Medicaid Other Individual Health Coverage
Other (explain)_____________________________________
I am not enrolled in any health insurance plan, but do not want this coverage
SECTION 9 — COVERAGE CONDITIONS
• I am an employee or a retiree 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 Illinois or Dearborn Life Insurance Company. 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
Contract(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 my participation in the 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
Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
Life and Disability insurance is underwritten by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148. Dearborn Life Insurance Company is an independent Blue Cross and Blue Shield licensee. BLUE CROSS,
®
BLUE SHIELD
®
and the Cross and Shield Symbols are registered
service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
click to sign
signature
click to edit
bcbsil.com
bcbsil.com
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

2056801 232320.0919 IL Group Enrollment Template Member Application Form.indd

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 13 December 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document