Last Name: Social Security No: Group #
—
—
SECTION 10 — COVERAGE CONDITIONS
70313.1011
• I am an employee of the Employer named in this Enrollment Application. I am eligible to participate in the coverage(s) afforded by my Employer’s plan, which is either underwritten or administered by
Blue Cross and Blue Shield of Oklahoma (BCBSOK). 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 Contracts(s)/Plan(s).
• For individuals age 19 and over, I understand that the Health coverage for which I am applying may have a preexisting condition exclusion waiting period. (Does not apply to HMO)
• I agree that my Employer acts as my agent. I authorize necessary payroll deduction 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.
WARNING: ANY PERSON WHO KNOWINGLY, AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURER, MAKES ANY CLAIM FOR THE PROCEEDS OF AN
INSURANCE POLICY CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A FELONY.
Applicant’s Signature Date
2
I
n order to receive credit for preexisting condition waiting periods, you must provide information about the last 6 months of coverage (18 months if new/current coverage is self-funded) for you and any dependents listed.
I
f you have a Certificate of Creditable Coverage, please attach a copy to this enrollment application. (If more than one plan was in effect, or if information is different for dependents, attach additional pages.) If Medicare,
p
lease complete the Medicare Coverage Information in Section 8. Please see instruction page for more information.
List names of every individual covered:
Previous Coverage Policyholder Name Birth Date (
MM/DD/YYYY)
n
Male Relationship to Applicant Group or Policy No. ID Number
n
Female
n
Self
n
Spouse
n
Dependent
Name of Previous Insurance Company, TPA, HMO: Effective Date (
MM/DD/YYYY)
Employer's Name: Employment Date under Previous Coverage
(MM/DD/YYYY)
Name of person covered: Medicare A (Hospital) Effective Date: ________________ End Date: ________________ Medicare HIC No.
Medicare B (Medical) Effective Date: _________________ End Date: ________________ (From Medicare Card)
Medicare D (Drug) Effective Date: ___________________ End Date: ________________
Medicare D (Drug) Carrier: ______________________________________
Name of person covered: Medicare A (Hospital) Effective Date: ________________ End Date: ________________ Medicare HIC No.
Medicare B (Medical) Effective Date: _________________ End Date: ________________ (From Medicare Card)
Medicare D (Drug) Effective Date: ___________________ End Date: ________________
Medicare D (Drug) Carrier: ______________________________________
Complete this section only if you or any of your dependents have other health and / or dental coverage that will not be cancelled when the coverage under this application
becomes effective. List names of each individual covered:
Group Coverage Name and Address of Other Insurance Carrier Effective Date
(
MM/DD/YYYY)
n
Yes
n
No
Name of Policyholder Birth Date (MM/DD/YYYY)
n
Male Relationship to Applicant
n
Female
n
Self
n
Spouse
n
Dependent
Employer’s Name Employment Date (MM/DD/YYYY) Health Group No. Health ID No. Dental Group No. Dental ID No.
SECTION 7 — OTHER COVERAGE INFORMATION
SECTION 8 — MEDICARE COVERAGE INFORMATION
DO NOT COMPLETE IF APPLYING FOR HMO
Name
n
Employee Reason for Declining Health:
n
Other Group Health Coverage; Carrier: __________________________________
n
Indian Health Services
n
Medicare
n
Medicaid
n
Other Individual Health Coverage; Carrier: __________________________________
n
Other, Explain: _____________________________________
n
I am not enrolled in any Health insurance plan, but do not want this coverage.
Name
n
Employee Reason for Declining Dental:
n
Other Group Dental Coverage
n
Medicaid
n
Indian Health Services
n
Individual Dental Coverage
n
Other, Explain:_____________________________________
n
I am not enrolled in any Dental insurance plan, but do not want this coverage.
Name
n
Spouse Reason for Declining:
n
Other Group Health Coverage
n
Medicare
n
Medicaid
n
Indian Health Services
n
Other Individual Health Coverage
n
Other, Explain:_____________________________________
n
I am not enrolled in any Health insurance plan, but do not want this coverage.
Name
n
Child Reason for Declining:
n
Other Group Health Coverage
n
Medicare
n
Medicaid
n
Indian Health Services
n
Other Individual Health Coverage
n
Other, Explain:_____________________________________
n
I am not enrolled in any Health insurance plan, but do not want this coverage.
Name
n
Child Reason for Declining:
n
Other Group Health Coverage
n
Medicare
n
Medicaid
n
Indian Health Services
n
Other Individual Health Coverage
n
Other, Explain:_____________________________________
n
I am not enrolled in any Health insurance plan, but do not want this coverage.
SECTION 9 — DECLINATION OF COVERAGE
SECTION 6 — PREVIOUS HEALTH COVERAGE INFORMATION
Please indicate reason for Medicare Eligibility:
n
Entitled Age
n
Entitled Disability
n
End-Stage Renal Disease
n
Disability and Current Renal Disease
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 as well as a preexisting condition waiting period.
Will Coverage be Continued?
n
Health
n
Dental
If No, Expected Cancel Date (MM/DD/YYYY) ____________________
Please indicate reason for Medicare Eligibility:
n
Entitled Age
n
Entitled Disability
n
End-Stage Renal Disease
n
Disability and Current Renal Disease
Type of Policy
n
Employee Only
n
Employee/Spouse
n
Employee/Child(ren)
n
Family
Type of Coverage
n
Health
n
Dental
Type of Policy
n
Employee Only
n
Employee/Spouse
n
Employee/Child(ren)
n
Family
Blue Cross and Blue Shield of Oklahoma is a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association.
