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 will not 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 benet 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 rst day of no coverage.
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 person 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.
Yourself (Member 1)
Please ll in all information that applies to you. (REQUIRED)*
PCP ID#—If your health plan requires you to choose a primary care physician (PCP), please ll 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 nd 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 www.bluecrossma.com, select Find a Doctor.
Other Insurance—Do you have other health insurance or Medicare? 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 its location (city and state).
To Add or Delete a Member—Are you adding or deleting a member under your existing membership? If yes, please ll in the areas in Sections 1 and 2. You may need help
from your employer to ll in Section 1. Then, give us the details about the members you’re adding or deleting in Section 3 and/or Section 4.
If you choose a Family membership, please ll 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 has
other insurance, please write the name of the other insurance company and its location (city and state).
Your Eligible Dependents (Members 3, 4, and 5)
If you choose a Family membership, please ll 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.
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 nancial account. If you have any questions please see your employer.
Note: If you are transferring from one medical/dental plan to another medical/dental plan, please provide notication that you will be continuing your personal savings account
by completing Section 5 of the Enrollment and Change form.
Signatures (Employer & Employee)
Employee: Please sign & date the application and return it to your employer. Employer: Please sign & date the application and return to Blue Cross Blue Shield of Massachusetts.
(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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© 2014 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.