1. To Be Filled Out by Your Employer
Company
Name
Current Medical Group #:
Medical Group #, Transferring To
Current BCBS ID #, If any Requested Effective Date
Date of Hire
Current Dental Group #: Dental Group #, Transferring To
MM DD YYYY MM DD YYYY
Type of Transaction
❒ ADD ❒ CANCEL
❒ CHANGE Three digit
❒ TRANSFER termination code
Remarks: (i.e., qualifying event for a new
add, change to family or other instruction)
❒ Open Enrollment
❒ New Hire
❒ COBRA
Change to Family
❒ Add Spouse
❒ Add Dependent
❒ Loss of Coverage (HIPAA Continuation of Coverage Letter Required)
❒
Other: __________________________________________
2. Yourself (Member 1)
What
products?
❒ Access Blue
❒ Blue Choice
❒ Blue Choice New England
❒ Blue Medicare Rx (Part D)
❒ Dental Blue
❒ HMO Blue
❒ HMO Blue New England
❒ Managed Blue for Seniors
❒ Medex (Group)
❒ Network Blue
❒ PPO
❒ Saver Blue
Membership Type
(Medical)
❒ Individual ❒ Family
Membership Type
(Dental)
❒ Individual ❒ Family
Your First
Name
M.I. Last
Name
Sex Date of Birth
Street Address/
P.O. Box #
Apt. # City/
Town
State Zip Code
Home
Phone ( )
Cell
Phone ( )
Email
Social Security #
(REQUIRED)
1
Other Insurance?
2
Y ❒ / N ❒
Other Insurance
Company Name
City / State
PCP ID #
(see instructions)
Name of
PCP
City / State Is this your current PCP?
Y
❒ / N ❒
Are you covered
by Medicare?
2
Y ❒ / N ❒
Part A Effective Date Part B Effective Date Part D Effective Date Medicare #
❒ 65+ ❒ Disabled ❒ ESRD
If Retired,
Date
MM DD YYYY MM DD YYYY MM DD YYYY Actively Working? Y ❒ / N ❒
3. Member 2
Please Check One: ❒ Spouse ❒ Domestic Partner ❒ Divorced Spouse (court ordered)
Plan Type:
❒ Medical ❒ Dental
First
Name
M.I. Last
Name
Sex Date of Birth
Social Security #
(REQUIRED)
1
Phone
( )
Other Insurance?
1
Y ❒ / N ❒
Other Insurance
Company Name
City / State
PCP ID #
(see instructions)
Name of
PCP
City / State Is this your current PCP?
Y ❒ / N ❒
Are you covered
by Medicare?
2
Y ❒ / N ❒
Part A Effective Date Part B Effective Date Part D Effective Date Medicare #
❒ 65+ ❒ Disabled ❒ ESRD
MM DD YYYY MM DD YYYY MM DD YYYY
If Retired,
Date
Actively Working? Y
❒ / N ❒
4. Your Eligible Dependents (Member 3, 4, and 5)
Dependent’s First Name
3.)
M.I. Last
Name
Sex Date of Birth
Social Security #
(REQUIRED)
1
PCP ID # (see
instructions)
Name of
PCP
Is this your current PCP? Y
❒ / N ❒ Full-time student and aged 19 or older ❒ Disabled and aged 26 or older ❒ Plan Type: ❒ Medical ❒ Dental
Dependent’s First Name
4.)
M.I. Last
Name
Sex Date of Birth
Social Security #
(REQUIRED)
1
PCP ID # (see
instructions)
Name of
PCP
Is this your current PCP? Y
❒ / N ❒ Full-time student and aged 19 or older ❒ Disabled and aged 26 or older ❒ Plan Type: ❒ Medical ❒ Dental
Dependent’s First Name
5.)
M.I. Last
Name
Sex Date of Birth
Social Security #
(REQUIRED)
1
PCP ID # (see
instructions)
Name of
PCP
Is this your current PCP? Y
❒ / N ❒ Full-time student and aged 19 or older ❒ Disabled and aged 26 or older ❒ Plan Type: ❒ Medical ❒ Dental
Please check if you are using separate forms for additional dependent children
❒
Total # of dependents: _________________________________
5. Personal Savings Account
HSA: Health Savings Account
Start Date End Date FSA Goal Amount (Please
see instructions for limits.): $
FSA: Health Flexible Spending Account
Start Date End Date Health: $
FSA: Dependent Care Reimbursement Account
Start Date End Date Dependent Care: $
6. Signature (Employer & Employee)
The information here is complete and true. I understand that Blue Cross and Blue Shield will rely on this information to enroll me and my dependents or to make changes to my
membership. I understand that I should read the subscriber certificate or benefit booklet provided by my employer to understand my benefits and any restrictions that apply to my
health care plan. I understand that Blue Cross and Blue Shield may obtain personal and medical information about me to carry out its business, and that it may use and disclose that
information in accordance with law. I acknowledge that I may obtain further information about the collection, use, and disclosure of my information in “Our Commitment to
Confidentiality,” Blue Cross and Blue Shield’s notice of privacy practices.
Employee’s Signature __________________________________Date _____________ Employer’s Signature ___________________________________ Date _____________
Please Read the Instructions
Before Filling Out This Form.
Please TYPE OR PRINT CLEARLY using blue
or black ink to avoid coverage delay or type in information
Enrollment and Change Form
Please mail to: P.O. Box 986001
Boston, MA 02298 or fax to 1-617-246-7531
Blue Cross Blue Shield of Massachusetts is an Independent Licence of the Blue Cross and Blue Shield Association.
1. REQUIRED: Under the Affordable Care Act, we are required to collect the Social Security number for you and any dependent enrolling in your plan.
2. If you have not indicated Y or N regarding your Medicare or other insurance status, you may receive a follow-up questionnaire.
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