SECTION 3a – ENROLLING MEMBERS: PRIMARY CARE PHYSICIAN (PCP)
List your choices for Primary Care Physician (PCP) and the names of the members each PCP applies to.
PCP Name, Address, and Medical Clinic (if known) Names of Covered Members
SECTION 4 – COBRA OR NON-COBRA CONTINUATION ENROLLMENT
You or your dependents may be entitled to COBRA or Non-COBRA continuation due to loss of current coverage. Select an option
for continuing coverage below, or select “None” if not electing.
Reasons for entitlement include loss of coverage due to: Termination of employment; Enrolled child no longer eligible; Medicare
entitlement; Reduction of hours; Divorce/termination of Domestic Partnership; Death.
Type of Continuation:
COBRA
Non-COBRA Continuation
None
Reason for Entitlement: ___________________________________________________ Date of Event: __________________
SECTION 5 – CURRENT AND PRIOR COVERAGE
Names of Covered Members Health Insurance Carrier
Dates of
Coverage
Coverage
Continuing? Coverage and Product Type
Carrier Name: Begin:
Yes
No
Coverage Type:
Group
Individual
Policy Number: Product Type:
End:
Medical
Dental
Carrier Phone: Medicare:
Part A
Part B
Part D
Reason for Medicare Entitlement (if applicable):
Age
Disability
Dual Entitlement
ESRD
Note: If coverage is provided for an enrolled child(ren) from a previous marriage or relationship, please attach a copy of any
court documentation that shows who is responsible for the health care expenses or insurance of the child(ren) so the carrier can
determine which coverage should pay rst.
If you need extra space, please request an additional form from your group administrator.
SECTION 6 – APPLICANT SIGNATURE
I have reviewed and agree to the provisions set out in Section 7 – Acknowledgments and Authorizations below.
Applicant Signature: ____________________________________________________________ Date: __________________
SECTION 7
– ACKNOWLEDGMENTS AND AUTHORIZATIONS
I hereby apply for enrollment, change, or termination of coverage as indicated above. Any coverage will be under the master
contract between Regence and my employer and subject to the terms and conditions of the certicate issued under it. I agree to
the employer’s enrollment provisions and certify that those I seek to enroll meet the eligibility criteria. I understand that coverage
does not start until I serve the employer’s eligibility waiting period established in Regence’s records.
I waive coverage of any eligible individual not listed on this application. I, or any other waived individual, may enroll at a later
time during my group’s annual open enrollment period or a Special Enrollment Period. If I waive enrollment for myself or any of
my dependents because of other health insurance coverage, I may enroll the waived individuals if I request enrollment within 60
days after the other coverage ends. In addition, I may enroll myself or new dependents within 60 days of marriage or domestic
partnership, or within 60 days of birth, adoption, or placement for adoption (if additional premium is due and paid for the child).
Please call 1 (800) 505-6801 for more information about these rules.
This application will become part of the contract between Regence and my employer and I understand only an ocer of Regence
may change the terms of the master contract, its amendments, or this application. I authorize my employer to act as my agent
in all matters of administration of the group coverage, and acknowledge that my employer is in no way an agent for Regence. I
agree to pay the appropriate premium rates for myself and my enrolling dependents in advance, and authorize payroll deduction
of premiums as required.
I authorize any source to release to Regence, any medical, health, employment, or insurance information requested for any enrolled
member. I acknowledge and understand that Regence may request or disclose health information, other than psychotherapy notes
(for which a separate authorization will be used), about me or my enrolled dependents from time to time to facilitate health care
treatment or payment, to assist with business operations necessary to administer health care benets, or as required by law.
More information about Regence’s uses and disclosures of information is provided in its Notice of Privacy Practices, available at
regence.com or by calling customer service.
I certify that all information provided on this form is true, correct, and complete, and understand Regence will rely on it in making
coverage and rating determinations. It is a crime to knowingly provide false, incomplete, or misleading information to an insurance
company for the purpose of defrauding the company. Penalties include imprisonment, nes, and denial of insurance benets. I
agree to promptly inform Regence in writing if any answer on this application later becomes inaccurate or incomplete before my
coverage takes eect.
Regence BlueShield: 1800 Ninth Avenue, Seattle, Washington 98101
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