State of Idaho
Medical Enrollment Application
If you have questions, call:
Department of Administration
Office of Group Insurance
650 W. State Street
Boise, ID 83720-0035
208-332-1860 or 1-800-531-0597
ogi@adm.state.id.us
Please complete each section on the front and back page of this application in ink.
Date of Application: __________________________________________
Effective Date (subject to BCI approval): ________________________
Group Number: 10040000
Applicant Information (Employee)
Your Name (first, initial, last) Blue Cross ID Number
(if currently enrolled)
Social Security Number Date of Birth (mm/dd/yyyy)
Male
Female
Mailing Address City, State, Zip Code Email Address (for official communications)
Marital Status: Single Married
Divorced Widowed
Hire Date Rehire Date
Phone Number
State Department or agency with which you are employed:
COMPLETE ONLY TO DECLINE ALL BENEFITS (Do not complete the information below this box.)
I hereby decline all benefits and understand they may be added at a later date and other eligibility requirements as outlined in the State of Idaho member
contract and employee handbook.
Signature: ________________________________________________________________________Date:____________________________________________________
Spouse & Eligible Children to be Enrolled (list all family members you wish to enroll)
Family Member’s Name (first, initial, last) Social Security No.
Relationship to Applicant (spouse, child, stepchild, etc.)
Date of Birth (mm/dd/yy)
Male
Female
Family Member’s Name (first, initial, last) Social Security No.
Relationship to Applicant (spouse, child, stepchild, etc.)
Date of Birth (mm/dd/yy)
Male
Female
Family Member’s Name (first, initial, last) Social Security No.
Relationship to Applicant (spouse, child, stepchild, etc.)
Date of Birth (mm/dd/yy)
Male
Female
Family Member’s Name (first, initial, last) Social Security No.
Relationship to Applicant (spouse, child, stepchild, etc.)
Date of Birth (mm/dd/yy)
Male
Female
Family Member’s Name (first, initial, last) Social Security No.
Relationship to Applicant (spouse, child, stepchild, etc.)
Date of Birth (mm/dd/yy)
Male
Female
Is spouse a State of Idaho employee? YES NO If YES, spouse’s name: _________________________________________________
Social Security Number: _______________________________________ Department: ________________________________________________
SPOUSE MUST COMPLETE A SEPARATE APPLICATION TO ENROLL OR TO DECLINE COVERAGE.
POLICY TYPE (please check one):
High Deductible
PPO
Traditional
Dental Enrollment*
Self only Self and dependents
Type of Enrollment Change Request
MEDICAL
Self only Self and 1 child
Self and spouse Self and 2+ children
Self, spouse and 1 child
Self, spouse and 2+ children
New Hire Transfer Adoption
Marriage Divorce Birth
Death Add Dependent Delete Dependent
Involuntary loss of coverage Court order (copy of court order required)
Date event occurred: ________________________
* If I decline dental coverage for my dependents, I understand that they may not be added to coverage until the State of Idaho conducts a special
open enrollment period.
FOR OFFICE USE ONLY
Auditor
Original applications must be submitted to your AGENCY HUMAN RESOURCES OFFICE
Form No. 3-700 (09-15)
OVER *
© 2015 by Blue Cross of Idaho, an independent licensee of the Blue Cross and Blue Shield Association
Statement of Understanding
By signing this application, I represent that all my answers are complete and
accurate, and that I understand and agree to the following conditions:
I agree to abide by all of the terms and conditions of the group policy.
No independent producer, agent or employee of the insurer, or my
employer can change any part of this application or waive the requirement
that I answer all questions completely and accurately.
The insurer may, at its discretion, request supplemental information
from me, any family member listed on this application or any health care
provider.
On behalf of myself and all enrolled family members, I understand if
the insurer discovers any intentional misrepresentation, omission or
concealment of fact in obtaining coverage that was or would have been
material to the insurer’s acceptance of a risk, extension of coverage,
provision of benefits or payment of any claim, the insurer may take action
against my employer, including but not limited to increasing premiums.
If this application is approved, coverage for myself and any eligible family
members named on this application will begin on the date assigned by the
insurer.
I acknowledge and understand my health plan may request or disclose
health information about me or my dependents (persons who are listed
for benefits coverage on the enrollment form) from time to time for the
purpose of facilitating health care treatment, payment or for the purpose
of business operations necessary to administer health care benefits; or as
required by law. For more information about such uses and disclosures,
including uses and disclosures required by law, please refer to the
Blue Cross of Idaho Notice of Privacy Practices that is available at
bcidaho.com.
My employer’s master group policy is the document that sets forth all
terms of my coverage, and no independent producer, agent or other
person can change the terms of the master group policy, any of its
amendments, or this application, except with an amendment issued
expressly for that purpose and signed by an authorized officer of the
insurer.
I agree that a facsimile or photocopy of my signature will serve the
same as an original.
I understand that this application will become part of the contract between
the insurer and my employer.
I affirm that I have reviewed all answers given on this application and,
regardless of whether an independent producer or other person has filled
out the answers for me, I verify that the answers are true and complete.
I have read and understand the group health plan dependent eligibility
requirements and further understand that I am required at the time a
dependent loses eligibility to submit an application removing the ineligible
dependent from coverage within thirty (30) days. I further understand and
agree that failure to do so may result in recovery of benefits to the extent
allowable by law.
APPLICATION MUST BE SIGNED AND DATED
Signature_______________________________________________
Date_____________________________
Current/Prior Coverage Information (Please complete for proper coordination of benefits administration.)
Is any person listed on this application now covered by any other health insurance, including Medicare, Medicaid, or other Blue Cross of Idaho policy?
Yes No If YES, please complete all information
below for each person listed on this application.
Applicant’s Name Name of Carrier Policy Number
Type of Policy
(Group or Individual)
Start Date of
Policy
(mm/dd/yy)
Will Current
Policy
Continue?
*
Employee
Ye s No
Spouse
Ye s No
Child
Ye s No
Child
Ye s No
Child
Ye s No
If any person listed on this application is covered by Medicare, please complete the following:
_______________________________________________________________ ________________________________________ ___________________________________________________
Name Medicare Beneficiary Number Reason for Medicare Entitlement (age, disability of ESRD)
Date of Medicare Entitlement: Part A ________________________________ Part B _________________________________
mm dd yy mm dd yy
*
If your current coverage will remain active, please indicate if coverage is for: q Medical q Dental q Vision
*
If your current coverage will be terminated, please indicate termination date:
mm dd yy
Disability Information
Total disability is a condition resulting from disease or accidental injury, as certified in writing by an attending physician, that renders the enrollee/
member incapable of performing the principal duties of regular employment/occupation for which he/she is qualified/trained and he/she is not
engaged in any work, profession or avocation for fees, gain or profit; or he/she is unable to engage in the normal activities of an individual of the
same age and gender.
Are you or any of your dependents currently totally disabled? YES NO (If YES, complete information below.)
______________________________________________________________________________________________________________________________________________
Nature of Total Disability
________________________________________________________ ___________________________________________________________________________________
Name of Totally Disabled Person Physicians Name Physicians Phone Number
________________________________________________________ ___________________________________________________________________________________
Date of Total Disability Physicians Address
Form No. 3-700 (09-15)