Fillable GROUP ENROLLMENT/CHANGE FORM Marlboro College 81243- (Marlboro College)

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GROUP ENROLLMENT/CHANGE FORM Marlboro College 81243- (Marlboro College)

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Country of origin: US
File type: PDF

U.S.A. forms for Marlboro College

BROWSE MARLBORO COLLEGE FORMS

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280.306 (6/12) PAGE 1 OF 2
EMPLOYER NAME
SOCIAL SECURITY NO.
CONTACT NUMBER
DATE OF EVENT _____________________ REASON FOR CHANGE EVENT BIRTH ADOPTION MARRIAGE/CIVIL UNION DIVORCE DEATH
LOSS OF COVERAGE** ENTER/DISCHARGE FROM MILITARY COURT ORDERED CHANGE** ADD/REMOVE SPOUSE/PARTY TO CIVIL UNION OR DEPENDENT (List in SECTION 5)
ADDRESS CHANGE NAME CHANGE PCP CHANGE OTHER (explain) ________________________________________________________________________________________________________
DATE HIRED/REHIRED/or BECAME FULL TIME
NEW HIRE RE-HIRE MEDICOMP SUPPLEMENT** (Attach copy of Medicare Card) SPOUSE TURNING AGE 65 OPEN ENROLLMENT CONTINUATION OF COVERAGE (COBRA/VIPER)
REFUSAL NEW GROUP TRANSFERRED FROM ANOTHER BCBSVT PLAN Transferring F ____
ACCOUNT NO.
(eight to nine characters i.e. 12345000 or T12345650)
MAILING ADDRESS
GROUP ENROLLMENT/CHANGE FORM
PLEASE TYPE OR PRINT (IN PEN)
An Independent Licensee of the Blue Cross and Blue Shield Association
MARITAL STATUS
SINGLE MARRIED/PARTY TO A CIVIL UNION
DOMESTIC PARTNER** DIVORCED WIDOWED
E-MAIL ADDRESS
(REQUIRED)
EMPLOYMENT STATUS
ACTIVE RETIRED CONTINUATION
HEALTH COVERAGE TYPE ( *Includes Party to a Civil Union or Domestic Partner )
EMPLOYEE ONLY EMPLOYEE/SPOUSE* EMPLOYEE/CHILD
EMPLOYEE/CHILDREN FAMILY
REQUESTED EFFECTIVE DATE
/ /
LAST NAME FIRST NAME
CITY STATE ZIP CODE
SECTION 1 - EMPLOYER/EMPLOYEE INFORMATION
SECTION 2 - NEW ENROLLMENT (Check one, then go to SECTION 5)
SECTION 3 - CHANGE (Check all that apply)
SECTION 4 - POLICY CANCELLATION - Signature Required
SECTION 5 - LIST ALL MEMBERS BELOW TO BE ADDED OR REMOVED
IMPORTANT NOTE: Federal Law mandates our collection of Social Security Numbers (SSN). If you are adding a dependent child, age 26 or older,
contact Customer Service (800) 247-2583 for further instructions.
MEMBER INFORMATION
ADD REMOVE - Subscriber
****NSSEMANTSRIFEMAN TSAL
Male
Female
DOB
Male
Female
DOB
Male
Female
DOB
Male
Female
DOB
Male
Female
DOB
Male
Female
DOB
PCP Name PCP or NPI No.***
VOLUNTARY CANCEL
(Subscriber Signature)
CANCEL CONTINUATION COVERAGE
LEFT EMPLOYMENT
OTHER, explain____________________________
(Subscriber Signature)
SIGN HERE BELOW:
X
PLEASE SEE SECTION 8 ON PAGE 2 FOR SUBSCRIBER SIGNATURE
PRIMARY CARE PHYSICIAN (PCP) INFORMATION
(IF MANAGED CARE)
Are you a current patient? Yes No
ADD REMOVE - Spouse/Party to a Civil Union
****NSSEMAN TSRIFEMAN TSAL
PCP Name PCP or NPI No.***
Are you a current patient? Yes No
ADD REMOVE - Dependent Child Incapacitated dependent 26/older
NSSEMAN TSRIFEMAN TSAL
PCP Name PCP or NPI No.***
Are you a current patient? Yes No
ADD REMOVE - Dependent Child Incapacitated dependent 26/older
NSSEMAN TSRIFEMAN TSAL
PCP Name PCP or NPI No.***
Are you a current patient? Yes No
ADD REMOVE - Dependent Child Incapacitated dependent 26/older
NSSEMAN TSRIFEMAN TSAL
PCP Name PCP or NPI No.***
Are you a current patient? Yes No
ADD REMOVE - Dependent Child Incapacitated dependent 26/older
NSSEMAN TSRIFEMAN TSAL
PCP Name PCP or NPI No.***
Are you a current patient? Yes No
Group Managers (GBMs) enrolling new employees may submit this form online at
www
.bcbsvt.com/groupenrollment. GBA or employee may complete all other transactions using our interactive PDF
at www
.bcbsvt.com/groupenrollmentform . Type information in, print, sign and submit one of three ways,
email: asinbox@bcbsvt.com
, fax: (802) 371-3329, or mail: BCBSVT P.O. Box 186 Montpelier, VT 05601.
* = Includes Party to a Civil Union or Domestic partner
** = Additional Documentation Required
*** = Physician Assistants & Nurse Practitioners are not valid
**** = SSN required age 45 and older (Federal mandate requires the collection of SSN)
APPLYING FOR VHP TVHP BLUECARE VFP J PLAN COMP
COMP HSA BLUE TVHP HSA BLUECARE __________________________
Marlboro College
81243-
SECTION 6 - OTHER INSURANCE INFORMATION
SECTION 7 - EXISTING HEALTH INSURANCE COVERAGE YOU INTEND TO REPLACE WITH THIS COVERAGE (NEW EMPLOYEES ONLY)
SECTION 8 - SUBSCRIBER SIGNATURE
MEDICARE
After you obtain health insurance coverage with us, will you or any of your dependents be covered with another health or dental insurance plan (Including Medicare)?
Yes (If yes, please complete the applicable section below) If No (Go to SECTION 8)
NAME of MEDICARE SUBSCRIBER SOCIAL SECURITY NO. MEDICARE/HIC NO. PART A EFFECTIVE DATE PART B EFFECTIVE DATE
HEALTH INSURANCE COMPANY NAME
ADDRESS
HEALTH DENTAL
POLICY HOLDER NAME POLICY/CERTIFICATE NO.
EFFECTIVE DATE
/ /
TYPE OF COVERAGE
1 PERSON 2 PERSON FAMILY
DENTAL INSURANCE COMPANY NAME
ADDRESS
POLICY HOLDER NAME POLICY/CERTIFICATE NO.
EFFECTIVE DATE
/ /
Do you have existing health care coverage that you are replacing with this coverage? Yes No
I certify that the statements on this application and all information furnished by me are true and complete to the best of my knowledge. I authorize any health care provider
to disclose to Blue Cross and Blue Shield of Vermont, or its designated agent, any information acquired in connection with my past or future care or treatment or that of
any dependent named herein or hereafter added to my coverage. I understand that no right whatsoever is created by this application and that the same shall not be
considered accepted unless and until the contract is actually issued by Blue Cross and Blue Shield of Vermont. I UNDERSTAND THAT MY BENEFITS ARE GOVERNED
BY THE PROVISIONS OF MY CERTIFICATE AND OUTLINE OF COVERAGE.
SUBSCRIBER’S SIGNATURE __________________________________________________________________________________________________________________________DATE _________________________
TYPE OF COVERAGE
1 PERSON 2 PERSON FAMILY
280.306 (6/12 ) PAGE 2 OF 2
You can visit our website at www .bcbsvt.com
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GROUP ENROLLMENTCHANGE FORM Marlboro College 81243- (Marlboro College)

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Completed 23 July 2020

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