Form Enr0296b - Empire Bluecross Blueshield Enrollment Form/change Form printable pdf download

Enrollment/Change Form

Thank you for choosing Empire BlueCross BlueShield (Empire). So that we may quickly and accurately process

your enrollment, please complete in full and sign in section 6.

SECTION 1: REASON FOR ENROLLMENT/CHANGE — Please complete section A, B or C.

A. NEW ENROLLMENT/ADDITION — Choose only one reason in bold

New hire Must indicate start date of full time employment in section 7. Leave Date of Change ﬁeld blank.

Date of change

(MM/DD/YY)

Open enrollment Leave Date of Change ﬁeld blank

Status change — Select only one

Marriage

Newborn

Adoption

Retirement

Medicare eligible For Medicare eligible only, answer the following questions:

Eligibility criteria — Select only one . . . . . . . . . . . . . . . . . . . . . .

Age 65+

Disability

End-stage renal disease

Active employee? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

Electing company coverage as primary coverage? . . . . . . . . . .

Yes

Electing Medicare-related coverage as primary coverage? . . .

Yes

(If company size is under 20 employees and endstage renal disease does not apply, you must choose this option)

Mandatory Right of Election — NYS Qualiﬁed dependents only. Must complete Section 3.

Original COBRA/NYS Continuation of coverage

Nature of COBRA/NYS event

(MM/DD/YY)

Loss of Coverage Must indicate last day covered in section 5.

Other:

B. CHANGE — Check all that apply. For all checked boxes below, please supply new information in sections 3 and 4.

Date of change

(MM/DD/YY)

Name

Address

Primary Care Physician (PCP)

Managed Dental Primary Care Dentist (PCD)

(HMO and POS plans only)

(If your company offers an Empire Dental plan)

C. CANCEL COVERAGE — Select only one

Note: If you are canceling your own coverage, please have your employer ﬁll out an Employee Termination Form . For other cancellations, please check the appropriate box

below and enter the name in the Applicant and Family portion in section 4.

Spouse/Dependent

Death

Divorce

Dependent no longer eligible

Date of event

(MM/DD/YY)

Other

SECTION 2: BENEFITS SELECTION

Medical Insurance

Select only one plan type:

Large group plans (101+ eligibles)

HMO

Empire Prism

EPO

Empire Total Blue EPO (HSA)

PPO

Direct POS

Empire Prism EPO

Empire Total Blue EPO HSA

Empire Prism

PPO

DS POS

HMO

with Blue Priority network

Empire Total Blue EPO (HRA)

Empire Total Blue PPO (HSA)

Direct HMO

with Blue Priority network

Empire Prism EPO Select

Empire Total Blue EPO HRA

Empire Total Blue PPO (HRA)

EPO

with Blue Priority network

Indemnity Select only one coverage type:

Hospital/Medical or

Hospital Only

Other:___________________________________________

Select only one medical coverage type:

Individual

Employee/Spouse

Parent/Child(ren)

Family

Dental Insurance

PPO Dental

Managed Dental

Voluntary Dental

Other Dental

Select only one coverage type:

Individual

Employee/Spouse

Parent/Child(ren)

Family

Select only one coverage type:

Individual

Employee/Spouse

Parent/Child(ren)

Family

Vision Insurance

Blue View Vision

1 Empire will facilitate the opening of a Health Savings Account in your name, as directed by your Employer. 2 The Blue Priority network includes selected physicians from our networks.

3 If your company offers an Empire Dental Plan. 4 If your company offers a Blue View Vision plan.

SECTION 3: APPLICANT INFORMATION

Last name

First name

M.I. Social Security no.

(required)

Sex

Date of birth

Marital status

Marriage date

Home phone no.

Daytime phone no.