A Division of Health Care Service Corporation, a Mutual Legal Reserve Company,
an Independent Licensee of the Blue Cross and Blue Shield Association
Please read the instructions on the inside thoroughly before completing this enrollment application/change form.
70313.1011
Enrollment Application/Change Form
Forms referenced above may be obtained by accessing the BCBSOK website at www.bcbsok.com, from your Marketing Service
Representative, or from your employer. If you have any questions, please contact your Marketing Service Representative.
P
LEASE READ THOROUGHLY BEFORE COMPLETING ENROLLMENT APPLICATION
/
C
HANGE FORM
Use a black or blue ballpoint pen only. Print neatly. Do not abbreviate.
ENROLLMENT APPLICATION
/
CHANGE FORM INSTRUCTIONS
SECTION 1 Check all the boxes that apply to indicate if you are a new enrollee or if you are requesting a change to your coverage. Indicate the event and date,
i
f applicable. Complete the additional sections that correspond to your selection.
New Enrollee: Complete all Sections where applicable.
A
dd Dependent: Complete all Sections where applicable.
If you are adding or enrolling a dependent due to Adoption or Placement for Adoption, you must provide legal documents.
If you are adding or enrolling a dependent due to court order, you must submit a copy of the court order or decree.
If you are applying for coverage for a disabled dependent child over the dependent age limit of your employer’s plan, certification is required by
the Social Security Administration and/or Blue Cross Blue Shield of Oklahoma. If certified disabled by Social Security, please attach a copy of the
certification document. A disabled dependent over the dependent age limit of your employers plan must be certified by medical underwriting.
C
ancel Enrollee: Complete Sections 1, 2, 4, and 10. In Section 4 include name, social security number, and date of birth of individual(s) cancelling.
Cancel Dependent: Complete Sections 1, 2, 4, and 10. In Section 4 include name and date of birth of individual(s) cancelling.
Declining Coverage: Complete Sections 2, 9, and 10.
S
ECTIONS 2 & 3 Complete all areas that apply to you.
SECTION 4 Complete all areas that apply to you and each dependent.
For HMO only: Those applying for HMO coverage should select a PCP for each individual to be covered. List the name of the physician and the
provider number from the provider directory or Provider Finder at www.bcbsok.com. Be sure to check the appropriate box for a new patient.
Change Primary Care Physician (PCP): In Section 1, check the “Other Change(s)” box, then complete sections 2, 3, 4, and 11. In Section 4, please
include enrollee's or dependent’s name, social security number, date of birth, and name and number of the new PCP.
Change Address / Name: In Section 1, check the “Other Change(s)” box, then complete sections 1, 2, and 11.
SECTION 5 Complete this section if you are applying for coverage for a disabled dependent child over the dependent child age limit of your employers plan.
A disabled dependent must be certified as disabled by the Social Security Administration and/or Blue Cross Blue Shield of Oklahoma. If certified disabled
by Social Security, please attach a copy of the certification documentation.
SECTION 6 Complete this section unless you are applying for HMO.
The health coverage for which you are applying may have a preexisting condition waiting period. On your group's first contract date or contract
anniversary date on or after September 23, 2010, a preexisting condition waiting period will not apply for individuals under the age of 19. Check with
your employer if you have questions regarding preexisting condition waiting period applicability for individuals under the age of 19.
SECTION 7 Complete this section if you or any dependent has other health care coverage through an employer (group coverage) that will not be cancelled when
the coverage under this application becomes effective.
SECTION 8 Complete this section if you or any of your dependents are covered by Medicare.
SECTION 9 Complete this section if you are declining health coverage for yourself and your dependents. Anyone declining coverage for any reason should complete
Section 9, not just those declining because of other coverage.
SECTION 10 Sign your name and date the enrollment application if you agree to the conditions set forth in this section. Your enrollment application should be submitted
to your employer, who will then submit your form to: Blue Cross and Blue Shield of Oklahoma P. O. Box 3283 • Tulsa, OK 74112-3283 or via
fax at 918-551-3179
70313.1011
IMPORTANT NOTICE DECLINATION OF HEALTH COVERAGE
If you are declining enrollment for yourself or your dependents (including your spouse) because of other health care coverage,
you may, in the future, be able to enroll yourself or your dependents in the plan if you request enrollment within 31 days after
your other coverage ends. In addition, if you have a new dependent as a result of a marriage, birth, adoption or becoming a
party in a Placement for Adoption, you may be able to enroll yourself and your dependents if you request enrollment within
31 days after the marriage, birth, adoption or Placement for Adoption.
Changes in state or federal law or regulations, or interpretations thereof, may change the terms and conditions of coverage.
PLEASE CHECK ALL THAT APPLY –IF YOU ARE DECLINING COVERAGE, COMPLETE SECTIONS 2, 9, AND 10 ONLY
Health Coverage (select one)
n
BlueLincs HMO
n
BluePreferred
®
n
BlueChoice
®
n
BlueTraditional
®
n
BlueOptions
®
n
HSA BLUE
n
BlueOptimize
SM
n
Other/Plan No. ______________
70313.1011
n
New Enrollee
n
Add Dependent
n
Open Enrollment
n
Other Change(s)
Are you applying as a result of a Special Enrollment Event?
n
No
n
Yes, Event Date: ____ / ____ / ____
Event:
n
Marriage
n
Birth, Adoption, Placement for Adoption (provide Legal documents)
n
Court Order (see instructions)
n
Loss of Other Coverage(provide Certificate of Creditable Coverage)
n
Insure Oklahoma (O-EPIC Provide Approval Letter)
n
Other (Explain)
N
OTE: Declination of Coverage (Complete Sections 2, 9 & 10)
n
Cancel Enrollee
n
Cancel Dependent
List names of those cancelling in Section 4 below
Event:
n
Divorce
n
Death
n
Terminated Employment
n
Other
Indicate Event Date: ____ / ____ / ____
S
ECTION 1 ENROLLMENT EVENTS
SECTION 2 PLEASE TELL US ABOUT YOURSELF
SECTION 3 SELECT YOUR COVERAGE
SECTION 4 COVERAGE OPTIONS
PLEASE CHECK ALL THAT APPLY
Health Enrollees (select one)
n
Employee Only
n
Employee /Spouse
n
Employee /Child(ren)
n
Family
n
I am not applying for
health coverage
Health Deductible
option $ ____________
(if more than one
is available)
Dental Enrollees (select one)
n
Employee Only
n
Employee /Spouse
n
Employee /Child(ren)
n
Family
n
I am not applying
for dental coverage
Dental Coverage
n
Yes
n
No
Plan No.,
if known:
1
Cancel Coverage:
n
Health
n
Dental
Employee/Enrollee’s Name PCP Name PCP No. New Patient?
n
Y
n
N
Dependent’s Name
n
Husband
n
Wife Dependent’s PCP Name PCP No. New Patient?
n
Y
n
N
Dependent’s Social Security No. Birth Date (MM/DD/YYYY) Address (if different) - No. And Street Address City State Zip
––
Dependent’s Social Security No. Dependent’s PCP Name PCP No. New Patient?
Dependent’s Name: _______________________________ _______
––
n
Y
n
N
Birth Date (MM/DD/YYYY) Home Address, if different — No. and Street Name/City/State/Zip
Dependent’s Social Security No. Dependent’s PCP Name PCP No. New Patient?
Dependent’s Name: _______________________________ _______
––
n
Y
n
N
Birth Date (MM/DD/YYYY) Home Address, if different — No. and Street Name/City/State/Zip
Dependent’s Social Security No. Dependent’s PCP Name PCP No. New Patient?
Dependent’s Name: _______________________________ _______
n
Y
n
N
Birth Date (MM/DD/YYYY) Home Address, if different — No. and Street Name/City/State/Zip
Last Name First Name MI (opt) Suffix Birth Date (MM/DD/YYYY) Social Security No.
––
Mailing Address - Street - Apt No. City State Zip
E-Mail Address
n
Male Home/Cell Phone No.
n
Female
Name of Employer Job Title Business Phone No. Employment Date (MM/DD/YYYY)
Eligibility Status:
n
Active Employee
n
Retired Employee - Date of Retirement:
n
COBRA Continuation
SELECT A PCP FOR HMO ONLY
ENROLLMENT APPLICATION/CHANGE FORM
Group No. Section No. Dept No. Social Security No.
Group No. Section No. Dept No. Category
On average, how many hours do
you work per week? (Required)
n
Son
n
Daughter
n
Other Eligible Dependent ______________
n
Son
n
Daughter
n
Other Eligible Dependent ______________
n
Son
n
Daughter
n
Other Eligible Dependent ______________
If not your natural child, stepchild or adopted child, are you
(or your spouse) financially responsible for this dependent?
n
Y
n
N
If not your natural child, stepchild or adopted child, are you
(or your spouse) financially responsible for this dependent?
n
Y
n
N
If not your natural child, stepchild or adopted child, are you
(or your spouse) financially responsible for this dependent?
n
Y
n
N
Is this dependent a natural child,
stepchild, or adopted child?
n
Y
n
N
If no, attach copy of court order
or decree.
Is this dependent a natural child,
stepchild, or adopted child?
n
Y
n
N
If no, attach copy of court order
or decree.
Is this dependent a natural child,
stepchild, or adopted child?
n
Y
n
N
If no, attach copy of court order
or decree.
A disabled dependent must be certified as disabled by the Social Security Administration and/or Blue Cross Blue Shield of Oklahoma.
If certified disabled by Social Security, please attach a copy of the certification documentation.
SECTION 5 DISABLED DEPENDENT
Name of Disabled Dependent Nature of Disability
Name of Disabled Dependent Nature of Disability
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
Employers 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.
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