Fillable Blue Cross Blue Shield Enrollment Form Fillable (City of Fitchburg)

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Blue Cross Blue Shield Enrollment Form Fillable (City of Fitchburg)

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The Blue Cross Blue Shield Enrollment Form Fillable (City of Fitchburg) form is 3 pages long and contains:

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  • 76 check-boxes
  • 92 other fields

Country of origin: US
File type: PDF

U.S.A. forms for City of Fitchburg

BROWSE CITY OF FITCHBURG (MA) FORMS

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Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. ®, SM Registered Marks and Service Marks of the
Blue Cross and Blue Shield Association. © 2017 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.
163537 36-3630 (11/17)
Thank you for choosing a Blue Cross
Blue Shield plan.
Please take a few minutes to help us set up your membership
by filling out the attached enrollment form.
Before You Begin
Please carefully read the instructions below.
For members of HMO Blue,
®
Network Blue,
®
Blue Choice,
®
HMO Blue New England,
SM
or Blue Choice New England
SM
: You’re required to choose a primary care physician (PCP) when you
enroll. Please choose a PCP from your plan’s provider directory. Be sure to read “PCP ID #” in Section 2.
List your PCP choice on your enrollment form. The PCP ID number can also be found by visiting
bluecrossma.com and selecting Find a Doctor.
For Access Blue
SM
Members: Although you’re not required to choose a PCP, we recommend you choose
one by following the instructions in Section 2 on the back of this page.
Important: Are you covered by Medicare or other insurance? We need to know if you or any family member
listed have Medicare and/or other insurance in addition to your Blue Cross Blue Shield of Massachusetts
plan. Please be sure to check either Y (for yes) or N (for no) in the correct box. This information will help us
accurately coordinate your benefits. Please follow the instructions in Sections 2 and 3.
Please print two copies of your completed application. Keep one for your records and give the other to your
employer to sign and mail to Blue Cross Blue Shield of Massachusetts. In order to complete your enrollment
request, your employer is required to sign the application.
Special Instructions for Student Coverage: If you’re seeking coverage for a full-time student dependent
over age 19, you may need to fill out a Student Certificate form. Check with your employer to see if this
coverage is available.
Blue Cross Blue Shield of Massachusetts
P.O. Box 986001
Boston, MA 02298
Fax: 1-617-246-7531
Instructions
Section 1
To Be Filled Out By Your Employer
Your employer will fill out this section.
Type of Transaction—Check the box(es) that apply.
Subscriber Cancellation Codes. If the subscriber won’t be continuing any Blue Cross Blue Shield coverage, carefully select one of the following and indicate the
three-digit code on the form.
Code # Reason for Canceling
041 • Changing to other health plan
• Voluntary termination
• COBRA cancellation (under 18 months or nonpayment)
042 • Over 65, changing to Group Medex
®
plan. (Requires Medicare A and B)
• Over 65, changing to direct-pay Medex plan. (Requires Medicare A and B)
• Over 65, changing to Medicare supplement other than Medex plans.
043 • Medicare (age =< 65)
Code # Reason for Canceling
061 • Left employment
• COBRA ending
063 • Transfer
064 • Cancellation as of original effective date
070 • Deceased
071 • Moved out of state (out of HMO service area)
076 • Military service
Note: If your subscribers are adding or dropping one benefit only (medical/dental), please indicate “add medical,” “add dental,” “cancel medical,” or “cancel dental”
in the “Remarks” section.
If your new hires are subject to a probationary period, please indicate the time frame in the “Remarks” section, as well as the qualifying events for new enrollees.
If a subscriber is being moved from an active group to a retiree group (within the same account), this is a transfer and not a termination. Please include the Medical
or Dental Group # transferring to.
Cancellation date will be the first day of no coverage.
Qualifying Events—Remarks:
To assist in the enrollment process, please use check boxes or write in applicable information in the “Remarks” section of the form.
• Open Enrollment—Check this box for open enrollment.
• New Hire—Check this box for new hires to the company.
• COBRA—Check this box if person is continuing coverage under COBRA.
• Add Spouse—Check this box if spouse is being added. Ensure date of marriage is within approved retroactive period.
• Add Dependent—Check this box if adding any dependent.
• Loss of Coverage—Check this box if employee lost coverage through spouse or parent. Please include HIPAA Continuous of Coverage Letter from prior company/insurer.
If you have questions, contact your account service representative.
• Other—Check this box if change to family requires additional explanation. Please write in the reason for change (e.g., court order, adoption, New Dependent Law under
HCR, legal guardianship, etc.). Include supporting documentation. If you have questions, contact your account service representative.
Section 2
Yourself (Member 1)
Please fill in all information that applies to you. (REQUIRED)*
PCP ID#—If your health plan requires you to choose a primary care physician (PCP), please fill in this section. Write the PCP ID number (not the telephone number)
of the doctor you have chosen to coordinate your health care. You’ll find the doctor’s PCP ID number in the provider directory for your health plan. If you need help
choosing a PCP, please call our Physician Selection Service at 1-800-821-1388. A representative will be happy to help you select a doctor. PCP ID number can be found
at bluecrossma.com, select Find a Doctor.
Other Insurance—Do you have other health insurance or Medicare in addition to your Blue Cross Blue Shield plan? Please be sure to circle either Y (for yes) or N (for no) )
in the correct box. If you have other insurance, please write the name of the other insurance company and your member identification number.
To Add or Delete a Member—Are you adding or deleting a member under your existing membership? If yes, please fill in the areas in Sections 1 and 2. You may
need help from your employer to fill in Section 1. Then, give us the details about the members you’re adding or deleting in Section 3 and/or Section 4.
Section 3
Member 2
If you choose a Family membership, please fill in this section if you want Member 2 to be covered. (REQUIRED)* (Note: Member 2 cannot be covered under
an Individual membership.)
Other Insurance—Does your spouse have other health insurance or Medicare? Please be sure to circle either Y (for yes) or N (for no) in the correct box. If your spouse or
partner has other insurance, please write the name of the other insurance company and your member identification number.
Section 4
Your Eligible Dependents (Members 3, 4, and 5)
If you choose a Family membership, please fill in this section for all children or other eligible dependents you want to be covered. (REQUIRED)* (Note: dependents cannot
be covered under an Individual membership.)
If you have more than three dependents to be covered, please use additional Enrollment Forms as needed. Please indicate on the form that additional forms have been used
and write in the total number of dependents you want to be enrolled.
Section 5
Personal Savings Account
Your employer may have chosen to offer a personal savings account alongside your medical offering. Please consult your open enrollment materials and/or your
HR department to determine if this applies to you.
For each option:
Start Date: Your start date will be considered established for tax purposes as of the start date of your medical plan, provided that you have signed, dated, and submitted
the completed application for these accounts on or before that date.
End Date: Your end date is the date you choose to stop deposits into the selected financial account. If you have any questions, please see your employer.
Note: If you are transferring from one medical/dental plan to another plan, please complete Section 5 of the Enrollment and Change Form to let us know that you will be
continuing your personal savings account..
Section 6
Signatures (Employer & Employee)
Employee: Please sign and date the application and return it to your employer. Employer: Please sign and date the application and return to Blue Cross Blue Shieldof Massachusetts.
Please mail to:
P.O. Box 986001
Boston, MA 02298
or fax to 1-617-246-7531
* Under the Affordable Care Act, we are required to collect the Social Security number for you and any dependent enrolling in your plan.
® Registered Marks of the Blue Cross and Blue Shield Association.
© 2017 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.
1. To Be Filled Out by Your Employer
Company
Name
Current Medical Group #: Medical Group # Transfering To:
Current BCBS ID #, If any Requested Effective Date
Date of Hire Current Dental Group #: Dental Group # Transferring To
MM DD YYYY MM DD YYYY
Type of Transaction
❒ ADD ❒ CANCEL
❒ CHANGE Three digit
❒ TRANSFER termination code
Remarks: (i.e., qualifying event for a new
add, change to family or other instruction)
❒ Open Enrollment
❒ New Hire
❒ COBRA
Change to Family
❒ Add Spouse
❒ Add Dependent
❒ Loss of Coverage (HIPAA Continuation of Coverage Letter required)
❒ Other: __________________________________________
2. Yourself (Member 1)
What
products?
❒ Access Blue
❒ Blue Choice
❒ Blue Choice New England
❒ Blue Medicare Rx (Part D)
❒ Dental Blue
❒ HMO Blue
❒ HMO Blue New England
❒ Managed Blue for Seniors
❒ Medex (Group)
❒ Network Blue
❒ PPO
❒ Saver Blue
Membership Type
(Medical)
❒ Individual ❒ Family
Membership Type
(Dental)
❒ Individual ❒ Family
First
Name
M.I. Last
Name
Sex Date of Birth
Street Address/
P.O. Box #
Apt. # City/
Town
State Zip Code
Home
Phone ( )
Cell
Phone ( )
Email
Social Security #
(REQUIRED)
1
Other Insurance?
2
Y ❒ / N ❒
Other Insurance Company Name Member Identification Number
PCP ID #
(see instructions)
Name of
PCP
City / State Is this your current PCP?
Y
❒ / N ❒
Are you covered
by Medicare?
2
Y ❒ / N ❒
Part A Effective Date Part B Effective Date Part D Effective Date Medicare #
❒ 65+ ❒ Disabled ❒ ESRD
If Retired,
Date
MM DD YYYY MM DD YYYY MM DD YYYY Actively Working? Y ❒ / N ❒
3. Member 2
Please Check One: ❒ Spouse ❒ Domestic Partner ❒ Divorced Spouse (court ordered)
Plan Type:
❒ Medical ❒ Dental
First
Name
M.I. Last
Name
Sex Date of Birth
Social Security #
(REQUIRED)
1
Phone
( )
Other Insurance?
1
Y ❒ / N ❒
Other Insurance Company Name
Member Identification Number
PCP ID #
(see instructions)
Name of
PCP
City / State Is this your current PCP?
Y ❒ / N ❒
Are you covered
by Medicare?
2
Y ❒ / N ❒
Part A Effective Date Part B Effective Date Part D Effective Date Medicare #
❒ 65+ ❒ Disabled ❒ ESRD
MM DD YYYY MM DD YYYY MM DD YYYY
If Retired,
Date
Actively Working? Y
❒ / N ❒
4. Your Eligible Dependents (Member 3, 4 and 5)
Dependent’s First Name
3.)
M.I. Last
Name
Sex Date of Birth
Social Security #
(REQUIRED)
1
PCP ID # (see
instructions)
Name of
PCP
Is this your current PCP? Y
❒ / N ❒ Full-time student and aged 19 or older ❒ Disabled and aged 26 or older ❒ Plan Type: ❒ Medical ❒ Dental
Dependent’s First Name
4.)
M.I. Last
Name
Sex Date of Birth
Social Security #
(REQUIRED)
1
PCP ID # (see
instructions)
Name of
PCP
Is this your current PCP? Y
❒ / N ❒ Full-time student and aged 19 or older ❒ Disabled and aged 26 or older ❒ Plan Type: ❒ Medical ❒ Dental
Dependent’s First Name
5.)
M.I. Last
Name
Sex Date of Birth
Social Security #
(REQUIRED)
1
PCP ID # (see
instructions)
Name of
PCP
Is this your current PCP? Y
❒ / N ❒ Full-time student and aged 19 or older ❒ Disabled and aged 26 or older ❒ Plan Type: ❒ Medical ❒ Dental
Please check if you are using separate forms for additional dependent children
❒
Total # of dependents: _________________________________
5. Personal Savings Account
HSA: Health Savings Account
Start Date End Date FSA Goal Amount (Please
see instructions for limits.): $
FSA: Health Flexible Spending Account
Start Date End Date Health: $
FSA: Dependent Care Reimbursement Account
Start Date End Date Dependent Care: $
6. Signature (Employer & Employee)
The information here is complete and true. I understand that Blue Cross and Blue Shield will rely on this information to enroll me and my dependents or to make changes to my
membership. I understand that I should read the subscriber certificate or benefit booklet provided by my employer to understand my benefits and any restrictions that apply to my
health care plan. I understand that Blue Cross and Blue Shield may obtain personal and medical information about me to carry out its business, and that it may use and disclose that
information in accordance with law. I acknowledge that I may obtain further information about the collection, use, and disclosure of my information in “Our Commitment to
Confidentiality,” Blue Cross and Blue Shield’s notice of privacy practices.
Employee’s Signature __________________________________Date _____________ Employer’s Signature ___________________________________ Date _____________
Please Read the Instructions
Before Filling Out This Form.
Please TYPE OR PRINT CLEARLY using blue
or black ink to avoid coverage delay or type in information
Enrollment and Change Form
Please mail to: P.O. Box 986001
Boston, MA 02298 or fax to 1-617-246-7531
Blue Cross Blue Shield of Massachusetts is an Independent Licence of the Blue Cross and Blue Shield Association.
1. REQUIRED: Under the Affordable Care Act, we are required to collect the Social Security number for you and any dependent enrolling in your plan.
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Blue Cross Blue Shield Enrollment Form Fillable (City of Fitchburg)

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Completed 14 July 2020

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