Fillable Large Group Member Application for Health, Dental, and (Roger Williams University)

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Large Group Member Application for Health, Dental, and (Roger Williams University)

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The Large Group Member Application for Health, Dental, and (Roger Williams University) form is 4 pages long and contains:

  • 1 signature
  • 67 check-boxes
  • 91 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Roger Williams University

BROWSE ROGER WILLIAMS UNIVERSITY FORMS

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Please be sure ALL information below is complete to avoid delays in processing.
Please print clearly using blue or black ink, or type information.
Section 1 Employer Information (To be completed by plan administrator.)
Group name Eective date
(mm/dd/yyyy)
Date of hire
(mm/dd/yyyy)
Group number Dept. number
Choose one: or Add dependent(s)
c Open enrollment c Spouse
c
New hire c Dependent
c COBRA
c
Loss of coverage (Certificate Date of event (mm/dd/yyyy) ____________
 of Creditable Coverage required)
( Must add within 30 days of marriage,
birth, or adoption of dependent.)
Section 2 Employee Information
Last name Sux First name M.I.
Home address (street/apartment number) City/town State ZIP code
Mailing address (street/apartment number, city/town, state, ZIP code—if dierent from above)
Date of birth
(mm/dd/yyyy)
Gender
c M c F
Social Security number
(xxx-xx-xxxx)*
What is your primary spoken
language?
Home phone number Cell phone number
Email address
Marital status (please check one)
c Single c Married c Divorced c Civil union c Common law c Domestic partner
Race (please check one)
cPrefer not to answer
c Hispanic or Latino
c American Indian or Alaska Native c Asian c Black or African American
c Native Hawaiian or other Pacific Islander c White cMultiracial
Primary care provider (PCP) name, street, city/town, state, and ZIP code (Required if electing BlueCHiP Flex or Blue Choice)
You must select a PCP for yourself and anyone on your plan, otherwise your enrollment may be delayed and benefits may be reduced.
Are you a current patient of the PCP listed above?
c Yes c No
Provider ID
Large Group Member Application for
Health, Dental, and Vision Insurance
c Other ___________________
* Social Security number is required in order to comply with the reporting requirements of the Mandatory Insurance Reporting Law. See
www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Mandatory-Insurer-Reporting-For-Group-Health-Plans/Overview.html
Group APP (08/17)
2
Section 3 Health Plan Options
Plan type
cMedical: c Enrollee only
c Enrollee and spouse c Enrollee and child(ren)
c Enrollee, spouse, and child(ren)
What product are you selecting?
cBlueCHiP
cBlue Choice New England
cHealthMate Coast-to-Coast
Section 4 Spouse or Domestic Partner Information
Last name Sux First name M.I.
Home address (street/apartment number, city/town, state, ZIP code—if dierent from employee)
Date of birth
(mm/dd/yyyy)
Gender
c M c F
Social Security number
(xxx-xx-xxxx)*
What is your primary
language spoken?
Home phone number Cell phone number
Email address
Race (please check one)
cPrefer not to answer
c Hispanic or Latino
c American Indian or Alaska Native c Asian c Black or African American
c Native Hawaiian or other Pacific Islander c White
Primary care pr
ovider (PCP) na
me, street, city/town, state, and ZIP code (required if electing BlueCHiP Flex or Blue Choice)
Is this dependent a current patient of the PCP listed above?
c Yes c No
Provider ID
Group APP (08/17)
* Social Security number is required in order to comply with the reporting requirements of the Mandatory Insurance Reporting Law. See
www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Mandatory-Insurer-Reporting-For-Group-Health-Plans/Overview.html
3
Section 5 Dependent Information (If necessary, please attach dependent addendum.)
Dependent #1 First name Last name M.I. Relationship
c Son c Daughter
Date of birth
(mm/dd/yyyy)
Social Security number
(xxx-xx-xxxx)*
Email address
Prima
ry care provider (PCP) name, street, city/town, state, and ZIP code (required if electing BlueCHiP Flex or Blue Choice)
Is this dependent a current patient of the PCP listed above?
c Ye s c No
Provider ID
Dependent #2 First name Last name M.I. Relationship
c Son c Daughter
Date of birth
(mm/dd/yyyy)
Social Security number
(xxx-xx-xxxx)*
Email address
Pr
imary care provider (PCP) name, street, city/town, state, and ZIP code (required if electing Blue CHiP Flex or Blue Choice)
Is this dependent a current patient of the PCP listed above?
c Ye s c No
Provider ID
Dependent #3 First name Last name M.I. Relationship
c Son c Daughter
Date of birth
(mm/dd/yyyy)
Social Security number
(xxx-xx-xxxx)*
Email address
Pr
imary care provider (PCP) name, street, city/town, state, and ZIP code (required if electing BlueCHiP Flex or Blue Choice)
Is this dependent a current patient of the PCP listed above?
c Yes c No
Provider ID
Dependent #4 First name Last name M.I. Relationship
c Son c Daughter
Date of birth
(mm/dd/yyyy)
Social Security number
(xxx-xx-xxxx)*
Email address
P
r
imary care provider (PCP) name, street, city/town, state, and ZIP code (required if electing BlueCHiP Flex or Blue Choice)
Is this dependent a current patient of the PCP listed above?
c Ye s c No
Provider ID
c
Check here if Group Dependent Addendum form will be attached.
Group APP (08/17) continued ➤
* Social Security number is required in order to comply with the reporting requirements of the Mandatory Insurance Reporting Law. See
www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Mandatory-Insurer-Reporting-For-Group-Health-Plans/Overview.html
4
500 Exchange Street • Providence, RI 02903-2699
Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association.
08/17 IER-192451.8451
Section 6 Other Insurance
Are you or any of your
dependents covered by
other insurance?
c Yes c No
Name of other insurance company and name(s) of covered person(s):
Covered person 1
____________________________________________________
Insurance company ____________________________________________________
Member ID #1 ____________________________________________________
Covered person 2 ____________________________________________________
Insurance company ____________________________________________________
Member ID #2 ____________________________________________________
What is the name of your prior health
insurance carrier?
______________________________________________________
______________________________________________________
What was the date of termination? (mm/dd/yyyy)
______________________________________________________
If loss of coverage, please attach a copy of the
Certificate of Creditable Coverage.
Is anyone named in this application eligible
for Medicare?
c Ye s c No
If yes, name of eligible person
_________________________________________
Is the eligible person
c
Over 65
c
Disabled
Retired date (if applicable)
____________________________________
Medicare number
__ __ __ - __ __ - __ __ __ __ - _____
Eective dates:
(mm/dd/yyyy)
Part A (hospital): ______________________ Part B (medical): ______________________
Section 7 Signature
By signing this form, I certify the information is true and complete to the best of my knowledge.
Signature of applicant Date
sign
here
+
Group APP (08
/17)
Application rec’d date____________________ ID #_________________________________________
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Large Group Member Application for Health, Dental, and (Roger Williams University)

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Completed 1 February 2021

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