Fillable EMPLOYEE APPLICATION SECTION I INFORMATION REGARDING YOUR EMPLOYER

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EMPLOYEE APPLICATION SECTION I INFORMATION REGARDING YOUR EMPLOYER

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Page 1
_____
EMPLOYEE APPLICATION
NEW GROUP
OPEN ENROLLMENT
EFFECTIVE DATE OF COVERAGE:
BCBSAZ ID NUMBER
(
existing member
)
EMPLOYEE NUMBER (employer use only)
MEDICAL PLAN TYPE
PPO
PPO HSA QUALIFIED*
HMO
HMO HSA QUALIFIED*
PLAN NAME
DEDUCTIBLE
COINSURANCE
MEDICAL COVERAGE
EMPLOYEE ONLY
EMPLOYEE & SPOUSE
EMPLOYEE & CHILDREN
FAMILY
DENTAL
PPO
PRIME PPO
DHMO
PLAN NAME
DENTAL COVERAGE
EMPLOYEE ONLY
EMPLOYEE & SPOUSE
EMPLOYEE & CHILDREN
FAMILY
ARE YOU DECLINING COVERAGE FOR:
MEDICAL
DENTAL
SELF?
Y N
Y N
SPOUSE? Y N
Y N
DEPENDENT(S)?
Y N
Y N
If yes, include the appropriate reason code(s) in Section II below.
(A list of reason codes is found near the bottom of page 2.)
CONSUMER-DIRECTED HEALTHCARE ACCOUNTS:
Health Savings Account (HSA)
*HSA Qualified plan must be selected to enroll
Health Reimbursement Arrangement (HRA)
Dependent-Care Flexible Spending Account (DCFSA)
Limited-Purpose Flexible Spending Account (LPFSA)
Flexible Spending Account (FSA)
Accounts in this section must be offered by employer to enroll.
SECTION I – INFORMATION REGARDING YOUR EMPLOYER
EMPLOYER NAME
LOCATION
GROUP NUMBER
JOB CLASSIFICATION
I
II
OTHER (SEE EMPLOYER)
SECTION II – INFORMATION REGARDING THE EMPLOYEE
MARK ONE:
ADD
CHANGE
WAIVER
CODE
(SEE
BACK)
SOCIAL SECURITY NUMBER
Required. See (O) on page 2.
LAST NAME
FIRST NAME
M.I.
PHYSICAL ADDRESS (NUMBER, STREET, & APARTMENT NO.)
CITY
STATE
ZIP + FOUR
MAILING ADDRESS
CITY
STATE
ZIP + FOUR
DATE OF BIRTH (MM/DD/YYYY)
MALE
FEMALE
MARRIED SINGLE
DATE OF MARRIAGE (MM/DD/YYYY)
WORK TELEPHONE (AREA CODE AND NO.)
HOME TELEPHONE (AREA CODE AND NO.)
EMAIL ADDRESS
See page 2 (N) regarding
email authorization
OTHER COVERAGE
INFORMATION:
Will you or your dependents be covered by other health insurance in addition to BCBSAZ?
If yes, please complete the other coverage information below.
YES NO
OTHER HEALTH PLAN COVERAGE NAME
CARRIER PHONE NO. (AREA CODE & NO.)
POLICYHOLDER LAST NAME
ID/SOCIAL SECURITY NUMBER
GROUP/POLICY NO.
EFFECTIVE DATE (MM/DD/YYYY) MEDICARE CARD NO. PART A EFFECTIVE DATE PART B EFFECTIVE DATE
Complete the following for all dependents. If you have more than 3 dependents, complete a separate form. New employees: Complete the following information for each eligible
dependent including those declining or waiving coverage. Enrolled employees: To add or remove dependent(s) or change coverage options, only include the persons affected by the change.
1
MARK ONE:
ADD
DELETE
CHANGE
WAIVER
CODE
(SEE
BACK)
LAST NAME FIRST NAME
M.I.
SOCIAL SECURITY NUMBER
Required. See (O) on page 2
DATE OF BIRTH (MM/DD/YYYY)
MALE
FEMALE
RELATIONSHIP
OTHER HEALTH PLAN COVERAGE NAME
CARRIER PHONE NO. (AREA CODE & NO.)
POLICYHOLDER LAST NAME
IDENTIFICATION NUMBER
GROUP/POLICY NO.
EFFECTIVE DATE (MM/DD/YYYY)
MEDICARE CARD NO.
PART A EFFECTIVE DATE PART B EFFECTIVE DATE
2
MARK ONE:
ADD
DELETE
CHANGE
WAIVER
CODE
(SEE
BACK)
LAST NAME FIRST NAME
M.I.
SOCIAL SECURITY NUMBER
Required. See (O) on page 2
DATE OF BIRTH (MM/DD/YYYY)
MALE
FEMALE
RELATIONSHIP
OTHER HEALTH PLAN COVERAGE NAME
CARRIER PHONE NO. (AREA CODE & NO.)
POLICYHOLDER LAST NAME
IDENTIFICATION NUMBER
GROUP/POLICY NO.
EFFECTIVE DATE (MM/DD/YYYY)
MEDICARE CARD NO.
PART A EFFECTIVE DATE PART B EFFECTIVE DATE
3
MARK ONE:
ADD
DELETE
CHANGE
WAIVER
CODE
(SEE
BACK)
LAST NAME FIRST NAME
M.I.
SOCIAL SECURITY NUMBER
Required. See (O) on page 2
DATE OF BIRTH (MM/DD/YYYY)
MALE
FEMALE
RELATIONSHIP
OTHER HEALTH PLAN COVERAGE NAME
CARRIER PHONE NO. (AREA CODE & NO.)
POLICYHOLDER LAST NAME
IDENTIFICATION NUMBER
GROUP/POLICY NO.
EFFECTIVE DATE (MM/DD/YYYY)
MEDICARE CARD NO.
PART A EFFECTIVE DATE PART B EFFECTIVE DATE
_____
I certify to all of the following on behalf of myself and the persons listed on this application as eligible dependents: (1) I have read this entire form; (2) I understand and agree to its terms; (3) I apply for
enrollment and/or waive group benefits as indicated on this form, subject to all terms and conditions of the coverage, as offered by my employer; (4) the information I have provided is accurate and complete,
and I understand that provision of false information may result in fines and criminal penalties; and (5) if any part of any premium for coverage or other financial services will be paid through payroll deduction,
I authorize my employer to periodically deduct from my wages, and remit amounts necessary to continue the coverage and any services.
X
EMPLOYEE’S SIGNATURE DATE
_____
_____
PAGE 1 OF ____________ ____________PAGE 2 OF
ACKNOWLEDGMENTS, AGREEMENTS, AND AUTHORIZATIONS APPLICABLE TO EMPLOYMENT-BASED HEALTH BENEFIT PLAN COVERAGE OFFERED
BY OR ADMINISTERED THROUGH BLUE CROSS BLUE SHIELD OF ARIZONA (BCBSAZ), an independent licensee of the Blue Cross Blue Shield Association
On behalf of myself and the persons listed on this application as eligible dependents, I acknowledge, agree, and authorize the following:
A. I have received information summarizing the terms and conditions of the health coverage available through my employment (“Coverage”). The Coverage is either (a) group health
insurance that my employer has purchased from BCBSAZ; or (b) a group benefit plan, for which BCBSAZ provides certain administrative, claims payment, and utilization management
services, and provider network access, but does not assume financial risk or obligation for claims.
B. I have carefully reviewed this entire application form and the answers I’ve provided. My answers are material to BCBSAZ. BCBSAZ will rely on my information to determine my
employer group’s eligibility for BCBSAZ coverage or administrative services, and to establish premium rates or administrative fees for my employer group.
C. My application includes any other enrollment forms I complete when applying for this coverage. This completed application becomes a part of my group’s contract with BCBSAZ,
except for any provisions related to life and disability coverage or separate financial accounts (HSA, FSA, HRA).
D. BCBSAZ does not underwrite or guarantee any separate life and/or disability insurance that may be offered by my employer group health plan. BCBSAZ is independent from any
companies that offer such coverage.
E. BCBSAZ does not administer or guarantee any separate financial account or arrangement (HSA, HRA, FSA) that may be part of the group benefit plan sponsored by my employer.
BCBSAZ is independent from any companies that administer such coverage or accounts.
F. My coverage shall become effective only when BCBSAZ: (1) reviews and accepts this application and (2) issues coverage to my employer group and me on effective dates assigned by
BCBSAZ in accordance with the employer’s terms for coverage.
G. The contract between my employer group and BCBSAZ controls the administration of this group coverage. The Coverage is subject to change, as permitted under applicable state and
federal law, and in accordance with the terms of the contract between my employer and BCBSAZ. My employer is responsible for notifying me of all changes, including termination of
the employer group contract for any reason.
H. If the contract between my employer group and BCBSAZ is terminated, I may be eligible for other coverage as required under state and/or federal law.
I. BCBSAZ, its reinsurers, or their respective authorized representatives may need to obtain medical information to process claims, and may collect personal information from
someone other than me or one of the proposed covered persons. I authorize any physician, practitioner, hospital, clinic, or other health-related provider or facility to furnish my
health information, including information related to drug use, alcoholism, mental illness, HIV, and AIDS (but not genetic testing or family history), to BCBSAZ, its reinsurers, and their
respective authorized representatives. BCBSAZ may use this information, and any of my information already in its possession to process claims. When permitted by law BCBSAZ may
disclose this information to third parties without my permission.
J. If I am declining enrollment for myself or my dependents (including my spouse) because of other health or dental coverage, I may be able to enroll myself and my dependents in this
BCBSAZ plan if my dependents or I lose eligibility for the other coverage (or if the employer group stops contributing towards my or my dependents’ other coverage). I must request
enrollment in this Coverage within 30 days after other coverage ends. For a complete list of special enrollment events, please refer to your Benefit Plan Booklet.
K. If I have a new dependent as a result of marriage, birth, adoption, or placement of adoption, I may be able to enroll myself and/or my dependents, if I request enrollment within
31 days (60 days for small groups*) after marriage, birth, adoption, or placement of adoption. For a complete list of special enrollment events, please refer to your Benefit Plan Booklet.
(To request special enrollment or obtain more information contact: Group Enrollment Services at 602-864-4456 or 1-800-232-2345, ext. 4456.)
L. Information regarding other health plan coverage is not used to determine preexisting conditions for BCBSAZ plans beginning or renewing on or after January 1, 2014.
M. I am responsible for any costs associated with obtaining medical records needed to process claims.
N. By including my email address on this form, I authorize BCBSAZ to send me information via email. I can change my email address or rescind this permission at any time by contacting
BCBSAZ through azblue.com.
O. Federal statute and BCBSAZ business processes require BCBSAZ or my employer plan sponsor to obtain the Social Security number (SSN) for most applicants.
Reason Codes for Declining/Waiving Coverage
(subject to BCBSAZ’s Group Underwriting Participation Guidelines)
A - Does not wish to be covered – no other coverage
B - Covered by spouse’s or parents’ employer group plan
C - Covered by TRICARE
D - Covered by AHCCCS
E - Covered by IHS (Indian Health Services)
F - Covered by Medicare
G - Married Coworkers
H - Individual coverage purchased directly from carrier
I - Individual coverage purchased on Healthcare Marketplace
* Employers are considered small groups for purposes of the Affordable Care Act (ACA) if the average number of total employees on business days during the previous calendar year
is 50 or fewer.
Blue Cross Blue Shield of Arizona (BCBSAZ) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.
Si usted, o alguien a quien usted está ayudando, tiene preguntas acerca de BCBSAZ, tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un
intérprete, llame al 602-864-4884.
Díí kwe’é atah nílínigíí Blue Cross Blue Shield of Arizona haada yit’éego bína’ídí[kidgo éí doodago Háida bíjá anilyeedígíí t’áadoo le’é yína’ídí[kidgo
beehaz’áanii hól- díí t’áá hazaadk’ehjí háká a’doowo[go bee haz’ą doo bąąh ílínígóó. Ata’ halne’ígíí koj’ bich’į’ hodíilnih
1-877-475-4799.
Page 2
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19296 0920
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EMPLOYEE APPLICATION SECTION I INFORMATION REGARDING YOUR EMPLOYER

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Completed 23 December 2020

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