Form 22840.0111 - Enrollment And Change Form
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1
2HMO/CPO Provider Selection
Enrollment and Change Form
Please print clearly in ink. This form should be used to complete your Blue Cross and Blue Shield of Illinois (BCBSIL) HMO or CPO coverage enrollment
and is required in addition to the Illinois Standard Health Employee Application. This form can also be used to change your HMO providers or CPO
network selections. Please complete all sections for yourself, your spouse/domestic partner and your dependents. If more space is required, a copy of this
form or a separate piece of paper may be attached.
If Your Are Enrolling/Changing HMO Coverage
If You Are Enrolling/Changing CPO Coverage
• You must select a Medical Group or IPA (Independent Practice Association)
• You must select a CPO Network that will apply to all persons being covered.
and a Primary Care Physician (PCP) for each person to be covered.
• Please enter the name and number of the CPO Network
• Please enter the name and numbers for both the Medical Group/IPA
• The CPO Network number is 3 or 4 characters: the letters "CO"
selection and the PCP selection for each person. If available, also enter
followed by 1 or 2 digits.
the National Provider Identification (NPI) number.
• CPO Network information can be found using the Provider Finder
• The Medical Group/IPA number is 3 digits. The PCP number is 9 digits.
tool on .
The NPI number is 10 digits.
• The PCP selected must be from within your Medical Group/IPA.
For HMO/CPO Coverage
• You may choose a different Medical Group/IPA for each person.
• If you are already enrolled and only changing your provider or network
• Female members may also choose a Woman's Principal Health Care
selection, enter your Group and Member Identification numbers found on
Provider (WPHCP) from within your Medical Group/IPA. A WPHCP may
your BCBSIL ID card.
be seen for care without referrals from your PCP, however, the WPHCP must
• Sign and date this form on page 2.
be affiliated with or employed by your Medical Group/IPA.
• Medical Group/IPA, PCP, WPHCP and NPI provider information can be
found using the Provider Finder® tool on .
• Until we receive this information, you are not eligible to receive medical
services and your claims could be denied.
Employer Name ________________________________________________ Member ID Number_________________________________
Group/Section #________________________________________________ Effective Date ______________________________________
Employee Name (Last) ______________________________________________ (First) __________________________________ (MI) ________
Social Security Number:
Date of Birth:
/
/
Medical Group/IPA # __ __ __ Medical Group/IPA Name: ____________________________________________________________________________
PCP # __ __ __ __ __ __ __ __ __ PCP Name: __________________________________________________ NPI # __ __ __ __ __ __ __ __ __ __
WPHCP # __ __ __ __ __ __ __ __ __ WPHCP (Physician) Name: ________________________________________ NPI # __ __ __ __ __ __ __ __ __ __
C O
CPO Network # __ __ __ __ CPO Network Name: ________________________________________________________________________________
Spouse/Domestic Partner Name (Last)____________________________________ (First) __________________________________ (MI) ________
Social Security Number:
Date of Birth:
/
/
Medical Group/IPA # __ __ __ Medical Group/IPA Name: ____________________________________________________________________________
PCP # __ __ __ __ __ __ __ __ __ PCP Name: __________________________________________________ NPI # __ __ __ __ __ __ __ __ __ __
WPHCP # __ __ __ __ __ __ __ __ __ WPHCP (Physician) Name: ________________________________________ NPI # __ __ __ __ __ __ __ __ __ __
22840.0111
22840.0111
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
Page 1
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