2013 Enrollment Application/change Form - Blue Cross And Blueshield Of Texas (Page 4 of 4) in pdf

Last Name:

Social Security No.:

—

Group #

—

SECTION 6 — DISABLED DEPENDENT

Name of Disabled Dependent

Nature of Disability

Name of Disabled Dependent

Nature of Disability

If disabled child is over the dependent age limit of your employer’s plan, please attach a completed Dependent Child’s Statement of Disability form.

SECTION 7 — PREVIOUS HEALTH COVERAGE INFORMATION

HMO

-H

OMPLETE IF APPLYING FOR

OSPITAL

NDEMNITY

OVERAGE

In order to receive credit for preexisting condition waiting periods, you must provide information about the last 12 months of coverage (18 months if new/current coverage is self-funded) for you and any dependents listed.

If you have a Certificate of Creditable Coverage, please attach a copy to this enrollment application. (If more than one plan was in effect, or if information is different for dependents, attach additional pages.) If Medicare,

please complete the Medicare Coverage Information in Section 9. Please see instruction page for more information.

List names of every individual covered:

Previous Coverage Policyholder Name

Birth Date

Male

Relationship to Applicant

Group or Policy No.

ID Number

(MM/DD/YYYY)

Female

Self

Spouse

Dependent

Name of Previous Insurance Company, TPA, HMO:

Effective Date

Type of Coverage

Type of Policy

(MM/DD/YYYY)

Health

Employee Only

Employee/Spouse

Dental

Employee/Child(ren)

Family

Employer's Name:

Employment Date under Previous Coverage

Will Coverage be Continued?

Health

Dental

(MM/DD/YYYY)

If No, Expected Cancel Date

____________________

(MM/DD/YYYY)

SECTION 8 — OTHER COVERAGE INFORMATION

Complete this section only if you or any of your dependents have other health and / or dental coverage that will not be cancelled when the coverage under this application

becomes effective. List names of each individual covered:

Type of Policy

Group Coverage

Name and Address of Other Insurance Carrier

Effective Date

(MM/DD/YYYY)

Employee Only

Employee/Spouse

Yes

Employee/Child(ren)

Family

Name of Policyholder

Birth Date

Male

Relationship to Applicant

(MM/DD/YYYY)

Female

Self

Spouse

Dependent

Employer’s Name

Employment Date

Health Group No.

Health ID No.

Dental Group No.

Dental ID No.

(MM/DD/YYYY)

SECTION 9 — MEDICARE COVERAGE INFORMATION

Name of person covered:

Medicare A (Hospital) Effective Date: ________________

End Date: ________________

Medicare HIC No.

Medicare B (Medical) Effective Date: ________________ _

End Date: ________________

(From Medicare Card)

Medicare D (Drug) Effective Date: ___________________

End Date: ________________

Medicare D (Drug) Carrier: ______________________________________

Please indicate reason for Medicare Eligibility:

Entitled Age

Entitled Disability

End-Stage Renal Disease

Disability and Current Renal Disease

Name of person covered:

Medicare A (Hospital) Effective Date: ________________

End Date: ________________

Medicare HIC No.

Medicare B (Medical) Effective Date: ________________ _

End Date: ________________

(From Medicare Card)

Medicare D (Drug) Effective Date: ___________________

End Date: ________________

Medicare D (Drug) Carrier: ______________________________________

Please indicate reason for Medicare Eligibility:

Entitled Age

Entitled Disability

End-Stage Renal Disease

Disability and Current Renal Disease

SECTION 10 — DECLINATION OF COVERAGE

This is to certify the available coverage has been explained to me. I have been given the opportunity to apply for the coverage offered to me and my eligible dependents and have voluntarily elected to decline

the coverage as indicated below. If I desire to apply for coverage at a later date, I understand there may be a delay in the effective date of the coverage as well as a preexisting condition waiting period.

Name

Employee

Reason for Declining Health:

Other Group Health Coverage; Carrier: __________________________________

Medicare

Medicaid

Other Individual Health Coverage; Carrier: _______________________________

Other, Explain: __________________________________

I am not enrolled in any Health insurance plan, but do not want this coverage.

Name

Employee

Reason for Declining Dental:

Other Group Dental Coverage

Medicaid

Individual Dental Coverage

Other, Explain:_____________________________________

I am not enrolled in any Dental insurance plan, but do not want this coverage.

Name

Spouse

Reason for declining:

Other Group Health Coverage

Medicare

Medicaid

Other Individual Health Coverage

Other, Explain:_____________________________________

I am not enrolled in any Health insurance plan, but do not want this coverage.

Name

Child

Reason for declining:

Other Group Health Coverage

Medicare

Medicaid

Other Individual Health Coverage

Other, Explain:_____________________________________

I am not enrolled in any Health insurance plan, but do not want this coverage.

Name

Child

Reason for declining:

Other Group Health Coverage

Medicare

Medicaid

Other Individual Health Coverage

Other, Explain:_____________________________________

I am not enrolled in any Health insurance plan, but do not want this coverage.

SECTION 11 — COVERAGE CONDITIONS

• I am an employee of the Employer named in this Enrollment Application. I am eligible to participate in the coverage(s) afforded by my Employer’s plan, which is either underwritten or administered by Blue Cross and Blue Shield of Texas

(BCBSTX) or Dearborn National

Life Insurance Company. On behalf of myself and any dependents listed on this Enrollment Application, I apply for those coverage(s) for which I am

eligible. I state that the information given on this Enrollment Application is true and correct. I understand and agree that any intentional misrepresentation of a material fact made by me will invalidate my coverage(s).

• Only those coverage(s) and amounts for which I am eligible will be available to me. I understand that if this Enrollment Application is accepted, the coverage(s) will become effective in accordance with the provisions of the

Contracts(s)/Plan(s).

• For individuals age 19 and over, I understand that the Health coverage for which I am applying may have a preexisting condition exclusion waiting period. (Does not apply to HMO or In-Hospital Indemnity coverage.)

• I agree that my Employer acts as my agent. I authorize necessary payroll deduction by my Employer, if any, to cover the cost of my coverage(s). As applies to HMO coverage, I will accept an electronic copy of my coverage

documents (whether certificate of coverage or benefit booklet) if my Employer requests that BCBSTX deliver the information electronically. I understand that a hard copy is available to me upon request.

• I understand that my participation in the coverage(s) is subject to any future amendment. I also understand that all notices given to my Employer are applicable to me.

Applicant’s Signature

Date

Blue Cross and Blue Shield of Texas is a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield ssociation.

*Products and services marketed under the Dearborn National

™

brand and the star logo are underwritten and/or provided by Dearborn National

Life Insurance Company (Downers Grove, Illinois) in all states (excluding New York), the District of Columbia, the United States Virgin Islands, the

British Virgin Islands, Guam and Puerto Rico. Dearborn National

Life Insurance Company does not provide Blue Cross and Blue Shield of Texas products and services, and is a separate company.

54521.1012

EA/CF 1012