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 New Mexico, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
477868.0817
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
indicated in that section.
Open Enrollment: The period of time offered annually 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 due to an
event such as marriage*, divorce**, 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: This 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: B816PPO) 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.
SECTION 4
COVERAGE
OPTIONS
Complete all areas that apply to you and each dependent.
For HMO Plans:
• 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 bcbsnm.com. Be sure to check the appropriate box for a new patient.
Blue Preferred EPO
SM
and Blue Preferred Plus
SM
require PCP selection for each person covered.
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 and name and number of the new PCP.
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 disabled dependent coverage 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 Request for Coverage for Medically or Physically Impaired
Dependents document must be completed and submitted with this enrollment application, if applicable.
SECTION 6
OTHER
COVERAGE
Complete this section if you or any of your dependents 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.
477868.0817
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 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, birth, adoption, placement 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, 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.
Submit the enrollment application to your employer’s Enrollment Department, which will then submit your
form to: BCBSNM • PO Box 27630 • Albuquerque, NM 87125-7630 or via fax at 859-469-7767 or by email at
MembershipApps@bcbsnm.com.
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 domestic partnership (coverage
subject to your employer’s plan).
** The term “divorce” includes legal divorce and the comparable termination of a domestic partnership (coverage
subject to your employer’s plan).
*** The term “spouse” includes a legal spouse and a party to a 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.
Forms referenced above may be obtained by accessing the Blue Cross and Blue Shield of New Mexico (BCBSNM)
website at bcbsnm.com, or from your employer. If you are a current member and have questions, you may also call the
Customer Service number on the back of your member ID card.
477868.0817
ENROLLMENT APPLICATION/CHANGE FORM
1
477868.0817
Group # Section Social Security #
____________________
Account # Category
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 or Placement 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
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 Continuation n State Six-Month Continuation of Group Coverage (insured plans only)
SECTION 3 — SELECT YOUR COVERAGE PLEASE CHECK ALL THAT APPLY
Small Group Plans
Health Coverage (select one)
Blue PPO
SM
Blue HMO
SM
Blue EPO
SM
Blue Preferred EPO
SM
Blue Advantage HMO
SM
Other _____________________________
Plan # (required) ______________________
Who is covered? (select one)
Employee Only
Employee/Spouse***
Employee/Child(ren)
Family
I am not applying for health
coverage
BlueCare Dental
SM
Coverage
Yes
No
Who is covered?
(select one)
Employee Only
Employee/Spouse
Employee/Child(ren)
Family
I am not applying for
dental coverage
Large Group Plans
Health Coverage (select one)
BlueEdge HCA
SM
BluePPO Evolution
SM
BlueEdge
HSA
SM
HMO Blue Alternatives
SM
BlueEdge
HSA 100
SM
Blue Preferred Plus
SM
BlueNet
EPO
SM
Blue Preferred EPO
SM
BlueNet
H EPO
SM
Other _____________________________
Who is covered? (select one)
Employee Only
Employee/Spouse
Employee/Child
Employee/Child(ren)
Family
I am not applying for health
coverage
Dental Coverage
Yes
No
Plan # (required)
___________________
Who is covered?
(select one)
Employee Only
Employee/Spouse
Employee/Child
Employee/Child(ren)
Family
I am not applying for
dental coverage
Additional Coverage Options Supplemental Coverage Options
COBRA Six-Month Continuation BlueSecure
SM
Group Secondary to Medicare
Primary Language:
2
SECTION 4 — COVERAGE OPTIONS
PLEASE COMPLETE ALL AREAS THAT APPLY (Select a PCP for HMO, Blue
Preferred EPO and BluePreferred Plus plans only.)
Employee/Enrollee’s Name PCP Name PCP # New Patient?
Y N
Dependent’s Name
Husband Wife
Domestic Partner
Dependent’s PCP Name PCP # New Patient?
Y N
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 Social Security No.
– –
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, adopted child
or foster child?
Y N
Dependent’s Name
Son Daughter
Other Eligible Dependent
Dependent’s Social Security No.
– –
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, adopted child
or foster child?
Y N
Dependent’s Name
Son Daughter
Other Eligible Dependent
Dependent’s Social Security No.
– –
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, adopted child
or foster child?
Y N
SECTION 5 — DISABLED DEPENDENT
PLEASE COMPLETE IF APPLICABLE
Name of Disabled Dependent Nature of Disability
Name of Disabled Dependent Nature of Disability
If a disabled dependent is over the dependent age limit of your employer’s plan, please attach a completed Request for
Coverage for Medically or Physically Impaired Dependents 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
Yes
No
Individual
Coverage
Yes
No
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
Female
Relationship to Applicant
Self Spouse
Dependent
Employer’s Name Employment Date
(MM/DD/YYYY)
Health Group # Health ID # Dental Group # Dental ID #
* The term “marriage” includes legal marriage and the establishment of domestic partnership (coverage subject to your
employer’s plan).
** The term “divorce” includes legal divorce and the comparable termination of domestic partnership (coverage subject to your
employer’s plan).
*** The term “spouse” includes a legal spouse and a party to a domestic partnership (coverage subject to your employer’s plan).
Last Name: _________________________ Social Security #: | |
Group #
477868.0817
3
Blue Cross and Blue Shield of New Mexico, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
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
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 of the employer or a retiree named in this enrollment application. I am eligible to participate in the coverage(s)
afforded by my employer’s plan, which is underwritten or administered by Blue Cross and Blue Shield of New Mexico. 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 deductions 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 _______________________________
Last Name: _________________________ Social Security #: | |
Group #
477868.0817
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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
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