Form 10-20 - Dental Application And Change Form - Bcbs Form
ADVERTISEMENT
1DENTAL APPLICATION AND
CHANGE FORM
PLEASE COMPLETE AREAS BELOW – PLEASE PRINT
1. LAST NAME
FIRST NAME
INT. DATE OF BIRTH
SEX SOCIAL SECURITY NO.
OFFICE USE ONLY
APPLICANT
I.D.No.
MO.
DAY
YEAR
ADDRESS OF APPLICANT (Street)
(City)
(State)
(ZIP)
Group No.
2. CURRENT EMPLOYMENT INFORMATION
GROUP#
MARITAL STATUS
Effective Date
EMPLOYER’S NAME
SINGLE
MARRIED
Bergman Schools
DIVORCED
WIDOWED
PLN. PKG.
CH
RSN WWP
DATE OF HIRE
DEPT. CLOCK NO. OCCUPATION 3. BENEFIT SELECTION
Individual
Employee/Spouse
Comment
Family –
Employee/Child(ren)
list mbrs below
4. CURRENT INSURANCE INFORMATION
OTHER INSURANCE INFORMATION
Do you or any member of your family covered under this
Arkansas Blue Cross Dental Policy #: _________________________________
application have other dental insurance with another insurance
Arkansas Blue Cross Health Policy #: _________________________________
company?
NO
Health Advantage Health Member #: __________________________________
YES – List Name of company and policy number
__________________________________________________
5. CHANGE COVERAGE AS INDICATED BELOW
CHANGE TO INDIVIDUAL DUE TO:
CHANGE TO FAMILY DUE TO:
Death – Date: _________________________________
Marriage – Date:
Divorce – Date:________________________________
Other – Explain: _______________________________
Other: _______________________________________
______________________________________________
(If dependents are to be covered, list in Section 6)
CHANGE MY NAME TO (AS SHOWN ABOVE) FROM:
__________________________________________________
6. CHANGE IN DEPENDENT STATUS
Reason
Add Delete LAST NAME
FIRST NAME
M. INIT. Birthdate
Relationship
Sex
SSN
Date of
(for deletion only)
Change
AUTHORIZATION & SIGNATURE
I understand that no benefits for services of any kind are provided for treatment that was received prior to the effective date of
my dental coverage.
I do hereby authorize any dentist, hospital or other provider of medical services or supplies to make available to Arkansas
Blue Cross and Blue Shield upon request any and all medical records and facts pertaining to us and our physical condition.
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false
information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
Print Name of Applicant
Signature of Applicant
Date
Shannan Lovelace
Print Employer/Group Representative
Signature Employer/Group Representative
Date
10-20 R6/03
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business