Small Group Subscriber Change Request Form printable pdf download

Small Group Subscriber Change Request

Blue Shield of California and Blue Shield

of California Life & Health Insurance Company

All changes must be received within 31 days of the effective date of change. This form cannot be used for primary care physician (PCP) changes – subscriber

must call plan directly. Please refer to the phone number on the back of your ID card.

Employee identification – this section must be completed.

Subscriber ID number (from ID card)

Group number (from ID card)

Work telephone (

)

Home telephone (

)

Last name

First name

Home street address

Apt #

City

State

ZIP code

Group/employer name:

E-mail address

Changes

c Yes

c No Is this a change/correction of address?

c Yes

c No Is the change/correction of address for a dependent?

If yes, please indicate dependent name and address change: ____________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________

c Requested effective date: ____ / ____ / ________

c Correct/change email address to:

c Correct my Social Security number to: ____ ____ ____ – ____ ____ – ____ ____ ____ ____

(Copy of Social Security card, a photo ID, a letter of verification from the Social Security office, and a written statement of why the employee

is requesting the change must be attached)

c Transfer/add my coverage to: c HMO ______ c PPO ______ c POS ______ c Active Choice

* ______ c Shield Savings

______

c DHMO ______ c DPPO ______ c Vision ______ c Life Insurance

______

From Group No. ________________ to Group No. ________________ in my employer group.

Note: If transferring coverage to HMO, POS, or DHMO coverage, please complete Section A on page 2.

c Correct/change name to:

c Correct/change my date of birth from: ____ / ____ / ________ to: ____ / ____ / ________

c Additional changes/comments: _________________________________________________________________________________________________

c COBRA participant

c Qualifying event and date _____________________________________________________________________________________________________

Dependent coverage changes

Add dependent(s) – Complete section A

Requested effective date for additions: ____ / ____ / ________

c Date of marriage if adding spouse: ____ / ____ / ________

c Domestic partner – date of domestic partnership if adding ____ / ____ / ________

c Newborn child – date of birth: ____ / ____ / ________

c If court ordered custody, please give date and attach copy of legal documents: ____ / ____ / ________

c If adoption, enter date of adoption or date placed for adoption, and attach copy of legal documents: ____ / ____ / ________

c Enroll/reenroll dependent child – If reenrollment, date dependent was last covered on this group plan: ____ / ____ / ________

Cancel dependent(s)

Requested effective date for deletions: ____ / ____ / ________

c Date of divorce if canceling spouse: ____ / ____ / ________

c Domestic partner – date of domestic partnership termination: ____ / ____ / ________

c Other _______________________________________________________

PLEASE NOTE: A completed Refusal of Coverage (C19927) is required for dependent’s cancelling coverage but remaining eligible.

Please provide a copy of the HIPAA certificate if enrolling self and/or dependent(s) as a health plan participant during open enrollment (OE), or if you are

adding dependent(s) to your coverage outside OE with a qualifying event.

Qualifying event: ____________________________________________________________________ Qualifying event date: ____ / ____ / ________

Note: Newborn/adopted children or children placed for adoption require a completed Subscriber Change Request to be submitted within 31 days from the date

of birth/adoption to be added to your coverage.

Underwritten by Blue Shield of California Life & Health Insurance Company (Blue Shield Life).

1 Evidence of Insurability form may be required.

Please be sure to return all pages of this form as the second page contains your signature which is necessary to process these

changes. Fax requests to (209) 367-6475. Missing information may delay processing.

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