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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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