Fillable DIRECTIONS FOR COMPLETING APPLICATION FORM (Blue Cross and Blue Shield of Illinois)

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DIRECTIONS FOR COMPLETING APPLICATION FORM (Blue Cross and Blue Shield of Illinois)

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Please read the directions thoroughly and detach them before completing this form. Use black or blue ballpoint pen
only. Print neatly. Do not abbreviate.
Complete all fields answering each question as accurately as possible. If you are unsure or have questions about
any of the information requested on this form, please ask for guidance from your employer.
Q ENROLLEE: Check the reason you are completing this form.
Timely Enrollment: Your first opportunity to enroll after becoming eligible.
Special Enrollment: You are enrolling within 31 days of a special enrollment event as specified in the Federal
HIPAA regulations (e.g., birth, adoption or placement for adoption, marriage, divorce** or involuntary loss of
other coverage).
Membership Change: Any change to your current membership such as adding dependents, canceling
dependents or changing your benefits. This change may occur outside of open enrollment.
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.
W EFFECTIVE DATE OF BENEFITS: Enter requested effective date and your group, section and identification
numbers.
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.
E EMPLOYEE/FORMER EMPLOYEE STATUS: Check the appropriate box to indicate whether you are an Active,
COBRA, IL Continuation or Retiree employee.
R COBRA/IL Continuation: If you are a COBRA/IL Continuation enrollee, enter the requested start and end date
for your COBRA/IL Continuation benefits. The remaining COBRA/IL Continuation information will be completed
by Blue Cross and Blue Shield of Illinois (BCBSIL).
T COVERAGE APPLIED FOR: Check all coverages that you are enrolling for based on the plans offered by
your employer. If you previously had BCBSIL coverage, enter the prior group, section and identification numbers
at the bottom of this section. If you are enrolling for Family Coverage, be sure to include information on family
members in Section I. If you are declining coverage, read, complete and sign Sections Y and }. If you are
unsure of your group size or whether your plan is Standard or Custom, please ask for guidance from your employer.
Y CHANGES TO EXISTING MEMBERSHIP: Check all boxes that apply to change coverage, add or cancel
dependents, or cancel coverage. If you are changing your primary care physician (PCP) or Woman's Principal
Health Care Provider (WPHCP), circle the reason(s) why at the bottom of this section.
NOTE: Usually Medical Group/Individual Practice Association (IPA) changes are not allowed if a member or
dependent is receiving in-hospital care or is in the third trimester of pregnancy.
To add a dependent, check the appropriate box. Members may add dependents within 31 days of a
qualifying event (e.g., marriage, birth and/or adoption of a child or during open enrollment). Enter the date
of the qualifying event. NOTE: List only those dependents to be added in Section I. If coverage is changing
from Individual to Family, check the appropriate box in Section Y. See your employer for other requirements
to add dependents.
To cancel a dependent, check the appropriate box. Enter the date the dependent is to be canceled from
coverage. NOTE: List only those dependents to be canceled in Section I. If coverage is changing from Family
to Individual, check the appropriate box in Section U.
ENROLLMENT APPLICATION AND POLICY CHANGE
DIRECTIONS FOR COMPLETING APPLICATION FORM
20005.1216
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
* Products and services marketed under the Dearborn National
®
brand and the star logo are underwritten and/or provided by
Dearborn National
®
Life Insurance Company (Downers Grove, IL) and certain of its affiliates. Dearborn National Life Insurance
Company is a separate company that does not provide Blue Cross and Blue Shield of Illinois products or services. Dearborn
National Life Insurance Company is solely responsible for the life and disability products described in this application.
** The term "divorce" in Section 1 includes legal divorce and the comparable termination of a civil union or domestic partnership.
*
U EMPLOYEE INFORMATION: Answer every question that applies to you.
If changing name and/or address, check the appropriate box in Section Y and enter your Name and Address in
section U. Be sure that you have completed Section W.
Enter your social security and identification numbers.
• Include your employee identification number if you know it.
• Your social security number is used for internal administrative purposes and for other purposes required
or permitted by applicable law.
If you selected HMO coverage in Section T, you must select a Medical Group or IPA and 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 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 Participating IPA/Medical Group 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 selected CPO or CPO Value Choice, you must select a CPO Network.
If you selected Dental HMO, include your Dental HMO group number and select a Dental HMO office for each
person to be covered.
If you are covered by Medicare, enter your HIC number, which is the Medicare ID number on your Medicare ID
card. Enter the start and end dates where they apply for: Medicare A, Medicare B, End Stage Renal Disease
(ESRD), and Disability. The ESRD start date is the day ESRD regular course at dialysis begins, (or the date of
kidney transplant in the case of total renal failure). The disability start date is the date the beneficiary is entitled
to Medicare due to disability.
I FAMILY COVERAGE INFORMATION: Answer every question as it applies to your family. If you are changing
existing membership, list only those dependents to be added or canceled.
A) SPOUSE, DOMESTIC PARTNER, PARTY TO A CIVIL UNION — Enter complete information (gender,
date of birth, name, including last name if different). If you selected HMO coverage in Section T, or your
spouse, domestic partner, or party to a civil union is covered by Medicare, complete the HMO and Medicare
sections as instructed in Section U. NOTE: In some situations, your employer may not offer coverage for
spouses, domestic partners and parties to a civil union. Please contact your employer for more information.
B) CHILDREN — Enter complete information for your child(ren). If you selected HMO coverage in Section T,
or your dependent(s) is covered by Medicare, complete the HMO and Medicare sections as instructed
in
Section U. Space for additional dependents is provided on the second page of this application. If necessary
,
use a separate piece of paper and attach it to this application.
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 elect HMO or Blue Choice Select
SM
coverage, your dependents must live or
work within the defined service area.
O OTHER INSURANCE INFORMATION: If you have other insurance coverage, enter the information requested
completely. This information will allow for the proper coordination of your health care benefits.
P DEARBORN NATIONAL: If you are enrolling with Dearborn National, 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. If necessary, use a separate piece of paper and attach it to this application.
{ SIGNATURE LINE FOR NEW/CHANGING COVERAGE: Please read, date and sign this Section.
Your signature and the date are required.
} WAIVER OF COVERAGE: BCBSIL's policy requires that you (the employee) enroll in order to also enroll your
dependents. If you choose to waive any coverage, your dependents cannot enroll in that coverage. However, you
can enroll yourself in coverage and choose to waive it for any of your dependents.
Use this section to indicate if you do not wish to enroll yourself and/or any of your dependents in the following
types of coverage: Medical, Dental, Vision, Basic Life, Dependent Life, Short-Term Disability (offered only to
employees), Long-Term Disability (offered only to employees) and Voluntary Life (offered only to employees).
NOTE: This coverage waiver does not apply to any COBRA Continuation rights you might have.
20005.1216
ENROLLMENT APPLICATION AND POLICY CHANGE
Q
ENROLLEE:
New Enrollment: ) Timely ) Special
Open Enrollment: ) New Member ) Plan Change ) Add Dependents
W
EFFECTIVE DATE OF BENEFITS: ___/___/____
) Completion of Other Eligibility Requirements
Group #: Section #: Identification #:
E
EMPLOYEE/FORMER EMPLOYEE STATUS
) Active Employee ) COBRA Continuation ) IL Continuation ) Retiree, retirement date
___/___/____
R
COBRA / ILLINOIS CONTINUATION
) COBRA:
Start Date ___/___/____ Projected End Date ___/___/____
) IL Continuation Privilege:
Start Date ___/___/____ Projected End Date ___/___/____
Previously covered with group as:
) 1. Employee (termination of employment, reduction in hours, other)
) 2. Spouse (divorce** from employee, death of employee, other)
) 3. Dependent (reach age limit, other)
) 4. Spouse and Dependents (divorce** from employee,
death of employee, other)
T
COVERAGE APPLIED FOR: Check all that apply (add one Medical, Dental, Life, if applicable).
After checking coverage applied for or making changes to existing membership, complete Plan #, Group #, Section #, Name and Social Security #.
Mid-Market & Large Group Standard Plans 51+
Large Group Custom Plans 151+
Dental
) BlueCare Dental PPO
SM
) BlueCare Dental HMO
SM
) Individual / Employee ) Employee & Spouse
) Employee & Child(ren) ) Family
) Employee & Party to a Civil Union or Domestic Partner
Gender: ) Male ) Female
Enter Dental Group # if different than Medical Group policy #.
Dental Group #: _______________________________________________
Life
Dearborn National Group #: ___________________
Previous BCBSIL or HMO Membership
Group #: _________________________________
Section #: ________________________________
Identification #: ____________________________
Y
CHANGES TO EXISTING MEMBERSHIP: Check all that apply.
CHANGES
Date ___/___/____
) HMO Medical Group/IPA
†
) PCP and/or WPHCP
†
) Name ) Address
) Telephone ) Reinstate
) From PPO to HMO
) From HMO to PPO
) From HMO Illinois to
Blue Advantage HMO
) From Blue Advantage HMO to
HMO Illinois
) Medicare Coverage
) FDL Beneficiary
) Other: ____________
ADD DEPENDENTS
Date ___/___/____
) Marriage
) Newborn
) Adoption/Placement
) Legal Guardianship
) Other: ____________
CANCEL DEPENDENTS
Date ___/___/____
) Divorce**
) Age Limit
) Other: _____________
CANCEL (Check all that apply)
Date ___/___/____
) Terminate Coverage
) Waive Coverage
‡
) Leave/Layoff
) Out of Service Area Move
) Other:
____________________
____________________
____________________
____________________
____________________
____________________
____________________
NOTE:
Only list dependents to be added or
dropped in the Family Coverage
Information Section I.
†
After checking the appropriate A. Availability B. PCP moved office C. Location
physician change, circle reason: D. PCP added to Network E. Dissatisfied with PCP F. PCP office/facility undesirable
) PCP ) WPHCP G. Staff H. Other _________________________________________
‡
If not electing coverage, please read, complete and sign Section }.
Small Group 1-50
Affordable Care Act Plans
) PPO
) Blue Choice Preferred PPO
SM
) Blue Options
SM
) Blue Precision HMO
SM
) BlueCare Direct
SM
) Plan #: ____________
Small Group 1-50
Grandfathered and Grandmothered/Transitional Plans
) Blue Advantage
Entrepreneur PPO
SM
) Blue Choice Select PPO
SM
) BlueEdge Select HSA
SM
) BlueEdge HSA
SM
) BlueEdge HCA Direct
SM
) PPO Value Choice
) Blue Advantage HMO
SM
) Blue Advantage HMO
Value Choice
SM
)
Community Participation
Organization (CPO)
) CPO Value Choice
) Plan #: __________
20005.1216
) PPO
) Blue Advantage
HMO
) Blue Advantage
HMO Value
Choice
) Blue Choice Options
SM
) Blue Choice Select PPO
) BlueEdge HSA
) BlueEdge Select HSA
) Plan #: ____________
) Traditional
) PPO
) CPO
) CPO Value Choice
) HMO Illinois
®
) w/HCA
) Blue Advantage HMO
) w/HCA
) Blue Choice Options
) Blue Choice Select PPO
) BlueEdge HCA
SM
) BlueEdge HSA
) Vision
) Hearing
) Medicare Supplement
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
** The term "divorce" in Section 4 includes legal
divorce and the comparable termination of a
civil union or domestic partnership.
* Products and services marketed under the Dearborn National
®
brand and the star logo are underwritten and/or provided by
Dearborn National
®
Life Insurance Company (Downers Grove, IL) and certain of its affiliates. Dearborn National
®
Life Insurance
Company is a separate company that does not provide Blue Cross and Blue Shield of Illinois products or services.
*
) BlueEdge HCA Direct
) BlueEdge Select HCA
SM
) BlueEdge Select HSA
) BlueEdge Select HCA Direct
SM
U
EMPLOYEE INFORMATION:
Company Name: Group
#
:
Employee Last Name: Employee First Name: Mid. Initial
Email Address: Cell Phone #:
Street Address: Apt. #:
City: State: ZIP code:
Date of Birth: ___/___/____ Are You Eligible for Family Coverage: ) No ) Yes
Health Coverage Elected: ) Individual/Employee ) Employee & Spouse ) Employee & Party to a Civil Union or Domestic Partner
) Employee & Child(ren) ) Family
Gender: ) Male ) Female
Employee Social Security #: ________ — ______ — ___________
Employee Identification # (if known): ____________________________________________
Telephone #: Business: ( _____ ) ____________________ Home: ( _____ ) ___________________ Date of Hire: ___/___/____
Dept. #: ___________________ Payroll Location: __________________________ Employee Clock #: __________________________
If HMO: Medical Group/IPA #: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ Medical Group/IPA Name: ________________________________
PCP #: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ PCP Name: ____________________________________________
WPHCP Medical Group/IPA #: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ WPHCP Medical Group Name: ____________________________
WPHCP (Physician) #: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ WPHCP (Physician) Name: _____________________________________
If CPO/CPO Value Choice, Network #: ____________________________ If BlueCare Dental HMO, Office ID #: _______________________
Employment Status: ) Actively at Work ) COBRA/IL Continuation ) Retired If retired, retirement date: ___/___/____
Are you covered or applying for coverage under your employer’s health care plan, and are you also covered by Medicare? ) No ) Yes
If Yes, the section below must be completed:
HIC #: _________________ MEDICARE B: ESRD DIALYSIS: DISABILITY:
MEDICARE A: Start Date: ___/___/____ Start Date: ___/___/____ Start Date: ___/___/____
Start Date: ___/___/____ End Date: ___/___/____ End Date: ___/___/____ End Date: ___/___/____
I
FAMILY COVERAGE INFORMATION:
List all eligible dependents.
I
A
) Spouse ) Domestic Partner ) Party to a Civil Union
Gender: ) Male ) Female
Last Name (only if different): _________________________________ Date of Birth: ___/___/___
First Name: ______________________________________________ Social Security #: ________ — ________ — _____________
If HMO: Medical Group/IPA #:
___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Medical Group/IPA Name: ______________________________
WPHCP Medical Group/IPA #: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
PCP #: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ PCP Name: _______________________________________________
WPHCP Medical Group Name: __________________________________
WPHCP (Physician) #: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ WPHCP (Physician) Name: ____________________________________
If BlueCare Dental HMO: Office ID #:________________________
Are you covered or applying for coverage under your employer's health care plan, and are you also covered by Medicare? ) No ) Yes
If Yes, the section below must be completed:
HIC #: _________________ MEDICARE B: ESRD DIALYSIS: DISABILITY:
MEDICARE A: Start Date: ___/___/____ Start Date: ___/___/____ Start Date: ___/___/____
Start Date: ___/___/____ End Date: ___/___/____ End Date: ___/___/____ End Date: ___/___/____
20005.1216
I
FAMILY AND DEPENDENT COVERAGE INFORMATION:
List all eligible dependents: If disabled child is over the dependent age limit of your employer’s plan, please attach a completed
Dependent Child’s Statement of Disability form. 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.
I
B
) SON ) DAUGHTER Date of Birth: ___/___/____
Last Name (only if different): ____________________________ First Name: ____________________
) ELIGIBLE MILITARY PERSONNEL ) DISABLED DEPENDENT
Address (if different from employee’s address): _____________________________________________________________________
Social Security #: ________ — ________ — ____________ If HMO: Medical Group/IPA #: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Medical Group/IPA Name: PCP #: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ PCP Name: ____________________________________
WPHCP Medical Group/IPA #: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ WPHCP Medical Group Name: _____________________________
WPHCP (Physician) #: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ WPHCP (Physician) Name*: __________________________________
If BlueCare Dental HMO: Office ID #: ________________________
Are you covered or applying for coverage under your employer's health care plan, and are you also covered by Medicare? ) No ) Yes
If Yes, the section below must be completed:
HIC #: ________________ MEDICARE B: ESRD DIALYSIS: DISABILITY:
MEDICARE A: Start Date: ___/___/____ Start Date: ___/___/____ Start Date: ___/___/____
Start Date: ___/___/____ End Date: ___/___/____ End Date: ___/___/____ End Date: ___/___/____
) SON ) DAUGHTER Date of Birth: ___/___/____
Last Name (only if different): ____________________________ First Name: ____________________
) ELIGIBLE MILITARY PERSONNEL ) DISABLED DEPENDENT
Address (if different from employee’s address): _____________________________________________________________________
Social Security #: ________ — ________ — ____________ If HMO: Medical Group/IPA #: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Medical Group/IPA Name: PCP #: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ PCP Name: ____________________________________
WPHCP Medical Group/IPA #: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ WPHCP Medical Group Name: _____________________________
WPHCP (Physician) #: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ WPHCP (Physician) Name*: __________________________________
If BlueCare Dental HMO: Office ID #: ________________________
Are you covered or applying for coverage under your employer's health care plan, and are you also covered by Medicare? ) No ) Yes
If Yes, the section below must be completed:
HIC #: ________________ MEDICARE B: ESRD DIALYSIS: DISABILITY:
MEDICARE A: Start Date: ___/___/____ Start Date: ___/___/____ Start Date: ___/___/____
Start Date: ___/___/____ End Date: ___/___/____ End Date: ___/___/____ End Date: ___/___/____
) SON ) DAUGHTER Date of Birth: ___/___/____
Last Name (only if different): ____________________________ First Name: ____________________
) ELIGIBLE MILITARY PERSONNEL ) DISABLED DEPENDENT
Address (if different from employee’s address): _____________________________________________________________________
Social Security #: ________ — ________ — ____________ If HMO: Medical Group/IPA #: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Medical Group/IPA Name: PCP #: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ PCP Name: ____________________________________
WPHCP Medical Group/IPA #: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ WPHCP Medical Group Name: ____________________________
WPHCP (Physician) #: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ WPHCP (Physician) Name*: __________________________________
If BlueCare Dental HMO: Office ID #: ________________________
Are you covered or applying for coverage under your employer's health care plan, and are you also covered by Medicare? ) No ) Yes
If Yes, the section below must be completed:
HIC #: ________________ MEDICARE B: ESRD DIALYSIS: DISABILITY:
MEDICARE A: Start Date: ___/___/____ Start Date: ___/___/____ Start Date: ___/___/____
Start Date: ___/___/____ End Date: ___/___/____ End Date: ___/___/____ End Date: ___/___/____
20005.1216
20005.1216
O
OTHER INSURANCE INFORMATION:
If you or any of your family members have OTHER GROUP COVERAGE, Check all that apply.
) Health: Policy #: ____________________________ ) Dental: Policy #: __________________________________
) Prescription Drug Coverage: Policy #: ___________________________ ) Vision: Policy #: ____________________________
) Hearing: Policy #: __________________________
If Yes: Is the other insurance: ) Single Coverage ) Family Coverage
EMPLOYED BY: ___________________________________ Insured’s Name: ______________________________________________
Date of Birth: ___/___/____
Insurance Company Name: ____________________________________________________________________________________
Address: __________________________________________________________________________________________________
City: ________________________________________ State: _______ ZIP code: ___________ Telephone #:
____________________
P
DEARBORN NATIONAL:
The group Term Life & AD&D, STD and LTD products are underwritten by Dearborn National
®
Life Insurance Company.
Employee Job Title: __________________________________________________________ Class Type: ______________________
Basic Salary: $ ______________________ ) Hourly ) Weekly ) Semi-Monthly ) Monthly ) Annually
Check Coverage Applied For: Term Life/AD&D: ) No ) Yes $ _______________ Dependent Life: ) No ) Yes $ ______________
Weekly Income: ) No ) Yes $ _______________ Supplemental Life: ) No ) Yes $ ___________________
Long Term Disability: ) No ) Yes $ ___________________ ) Voluntary AD&D: $ ________________ ) Single ) Family
Permanent Life Insurance: ) No ) Yes $ ____________________
If Yes: ) Automatic Premium Loan or ) Replaces An Existing Policy
Beneficiary: Note: If more than one Beneficiary, interest will be equal unless otherwise indicated.
Last Name: _________________________________________________ First Name: ______________________________________
Relationship: _____________________________________
{
I APPLY FOR COVERAGE AS INDICATED ABOVE, for which I am or may become eligible under the agreement with Health Care Service Corporation
(providing hospital and medical, dental coverage and health maintenance coverage), and/or Dearborn National (providing the life and disability insurance)
(the Company). I have read the above statements and represent they are true and complete to the best of my knowledge. I authorize my employer/group to
deduct from my pay and remit any required contribution for the cost of said coverage. This authorization is to remain in effect until the Company is notified
by me in writing to the contrary. I understand that the benefits listed in the Certificate(s) will be available subject to the Terms and Conditions thereof
effective as listed in the Certificate(s) of Coverage.
Date Signed:
___
/
___
/____
Signature of Applicant: _________________________________________________________________________
}
If you are declining enrollment for yourself and/or eligible dependents (children, spouse, party to a civil union or domestic partner) because of other health
insurance coverage, you may in the future be able to enroll yourself or your dependents in this plan, provided that you request enrollment within 31 days
after your other coverage ends. In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able
to enroll yourself and your dependents, provided that you request enrollment within 31 days after the marriage, birth, adoption, or placement for adoption.
I DO NOT WISH TO ENROLL at this time and understand that the opportunity to enroll at any future time will be subject to such arrangements as
may be made with the Company. Not enrolling in:
Reason:
) Covered under spouse’s* employer-based health insurance plan (complete “Other Insurance Information” in Section
O
)
) Covered under a Medicare supplement plan
) Other (please explain)_________________________________________________
Date Signed:
___
/
___
/____
Signature of Applicant: _________________________________________________________________________
* The use of the term "spouse" in Section 12 includes a legal spouse, domestic partner or party to a civil union. All of the provisions of this section of the form that pertain to a spouse also apply to
a domestic partner or party to a civil union unless specifically noted otherwise.
Medical for ) Myself ) My spouse* ) My spouse and dependents ) My dependents ) Myself, my spouse and my dependents
Dental for ) Myself ) My spouse* ) My spouse and dependents ) My dependents ) Myself, my spouse and my dependents
Vision for ) Myself ) My spouse* ) My spouse and dependents ) My dependents ) Myself, my spouse and my dependents
Basic Life for ) Myself ) My spouse* ) My spouse and dependents ) My dependents ) Myself, my spouse and my dependents
Dependent Life for ) Myself ) My spouse* ) My spouse and dependents ) My dependents ) Myself, my spouse and my dependents
Voluntary Life for ) Myself ) My spouse* ) My spouse and dependents ) My dependents ) Myself, my spouse and my dependents
Short-Term Disability for ) Myself ) My spouse* ) My spouse and dependents ) My dependents ) Myself, my spouse and my dependents
Long-Term Disability for ) Myself ) My spouse* ) My spouse and dependents ) My dependents ) Myself, my spouse and my dependents
bcbsil.com
bcbsil.com
bcbsil.com
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
bcbsil.com
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DIRECTIONS FOR COMPLETING APPLICATION FORM (Blue Cross and Blue Shield of Illinois)

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Completed 10 June 2021

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