Enrollment And Change Form

Enrollment and Change Form

Please Read The Instructions

Before Filling Out This Form.

Please mail to: BCBSMA, P.O. Box 9145,

North Quincy, MA 02171-9145 or fax 617-246-7531

Please PRINT CLEARLY using blue or black ink

Blue Cross Blue Shield of Massachusetts is an

to avoid coverage delay or type in information.

Independent Licencee of the Blue Cross and Blue Shield Association

1. To Be Filled Out by Your Employer

Company

Current Medical Group #:

Medical Group #, Transferring To

Name

Current BCBS ID #, If any

Requested Effective Date

Date of Hire

Current Dental Group #:

Dental Group #, Transferring To

MM

DD

YYYY

MM

DD

YYYY

(If canceling, please see

Remarks: (i.e., qualifying event for a new add, change to family or other instruction)

Type of

instructions for three digit

Transaction

termination code.)

Open Enrollment

Change to Family

Loss of Coverage

ADD

New Hire

Add Spouse

(HIPAA Continuation of Coverage Letter Required )

CHANGE

COBRA

Add Dependent

TRANSFER

Other________________________________________

CANCEL

2. Tell Us About Yourself ( Member 1 )

What

Kind of Membership

Kind of Membership

HMO Blue

Dental Blue

HMO Blue New England

Products are

(Medical)

(Dental)

Network Blue

Access Blue

Blue Choice New England

you selecting?

Individual

Individual

Blue Choice

PPO

Other (

Write Name of Plan)

Family

Family

Saver Product

Your First Name

M.I.

Last Name

Sex

Date of Birth

Street Address / P.O. Box #:

Apt. #:

City / Town

State

Zip Code

Social Security #:

Telephone #: (area code)

Other Insurance? *

Other Insurance Company Name

City / State

(

)

Y

/ N

PCP ID #: (see instructions)

Name of PCP

City/State

Is this your current PCP?

Mark X, if yes.

Are you Covered

Medicare #:

Actively Working

Part A Effective Date

Part B Effective Date

Part D Effective Date

by Medicare? *

Y

/ N

If Retired, Date:

Y

/ N

65+

Disabled

ESRD

MM

DD

YYYY

MM

DD

YYYY

MM

DD

YYYY

Spouse

Domestic Partner

Divorced Spouse (court ordered)

3. Tell Us About ( Member 2 )

Please check one:

Member 2’s First Name

M.I.

Last Name

Sex

Date of Birth

Street Address / P.O. Box #:

Apt. #:

City / Town

State

Zip Code

Social Security #:

Telephone #: (area code)

Other Insurance? *

Other Insurance Company Name

City / State

(

)

Y

/ N

PCP ID #: (see instructions)

Name of PCP

City/State

Is this your current PCP?

Mark X, if yes.

Is Member 2

Medicare #:

Actively Working

Part A Effective Date

Part B Effective Date

Part D Effective Date

Y

/ N

Covered by

Medicare? *

If Retired, Date:

Y

/ N

65+

Disabled

ESRD

MM

DD

YYYY

MM

DD

YYYY

MM

DD

YYYY

* If you have not indicated Yes or No regarding your Medicare or other insurance status, you may receive a follow-up questionnaire.

4. Tell Us About Your Dependents ( Member 3, 4, and 5 )

Dependent’s First Name

M.I.

Last Name

Sex

Full-time student?

3.)

Age 19 or Over

Y

/ N

Social Security #:

Date of Birth

PCP ID #: (see instructions)

Name of PCP

Is this your current PCP?

Mark X, if yes.

Dependent’s First Name

M.I.

Last Name

Sex

Full-time student?

Age 19 or Over

Y

/ N

4.)

Social Security #:

Date of Birth

PCP ID #: (see instructions)

Name of PCP

Is this your current PCP?

Mark X, if yes.

Dependent’s First Name

M.I.

Last Name

Sex

Full-time student?

5.)

Age 19 or Over

Y

/ N

Social Security #:

Date of Birth

PCP ID #: (see instructions)

Name of PCP

Is this your current PCP?

Mark X, if yes.

Please check if you are using separate forms for additional dependent children.

Total # of Dependents :

5. Select Personal Savings Account ( Blue Healthcare Bank Members Only )

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