"Employee Change Form for 1-50 Employee Small Groups - Anthem Bluecross Blueshield" - Maine

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Employee Change Form
For 1-50 Employee Small Groups
Maine
Instructions:
If you are cancelling coverage for a dependent or changing a name, please provide a reason in the designated sections. Complete electronically or in
black ink and return to your employer. Please use extra sheets of paper if necessary. NOTE: Some changes may be made by accessing anthem.com.
Section A: General Information
Employer name
Group no.
Employee last name
Employee first name
M.I.
Employee Social Security no.* (required)
Section B: Employee Information — Required
Reason for change –Required. Check all that apply.
o
Address change
o
Add spouse or Domestic Partner or dependent
o
Enrollment in Medicare (Fill in Section E)
o
o
o
Name change
Cancel spouse or Domestic Partner or dependent
Cancel coverage
o
o
o
Benefit change
Change Primary Care Physician (PCP)
Other:____________________________
o
Change Life and or Disability classification from _______to______
Event reason-Required. Check all that apply.
o
o
o
o
o
Add
Open enrollment (not applicable for life and disability products)
Marriage
Birth of child
Adoption of child
o
Change
o
Involuntary loss of coverage
o
Other insurance
o
Death
o
Divorce
o
o
Cancel
Other- please explain: _____________________________________________________________________________
Event date/Requested effective date- Required __________/______/_________ (MM/DD/YYYY)
Home address — Street and PO Box if applicable
City
State
ZIP code:
County
Birthdate (MM/DD/YYYY)
Sex
Marital status
o
Male
o
Female
o
Single
o
Married
o
Domestic Partner
Primary phone no.
Secondary phone no.
Email address
o
o
Primary Care Physician (PCP) name
PCP ID no.
Existing Patient?
Yes
No
PCP address
Section C: Family Information — Spouse and dependents to be added/changed/cancelled. Attach a separate sheet if necessary.
Event reason-Required. Check all that apply.
o
Add
o
o
o
o
o
Open enrollment (not applicable for Life and Disability)
Marriage
Birth of child
Adoption of child
Divorce
o
Change
o
Involuntary loss of coverage
o
Other insurance
o
Death
o
Other- please explain: ________________________________
o
Cancel
Event date/Requested effective date- Required __________/______/_________ (MM/DD/YYYY)
Spouse/Domestic Partner last name
First name
M.l.
Social Security
no.*(required)
Sex
Disabled?
Birthdate (MM/DD/YYYY)
Relationship to applicant
o
Male
o
Female
o
Yes
o
No
o
Spouse
o
Domestic Partner
PCP Name
PCP ID no.
Existing patient?
o
o
Yes
No
PCP Address
o
o
Does the Spouse/Domestic Partner have a different address?
Yes
No
If yes, please enter: ____________________________________________________________________________________________________
*Anthem Blue Cross and Blue Shield (Anthem) is required by the Internal Revenue Service to collect this information.
Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Maine, Inc. Independent licensee of the Blue Cross and Blue Shield Association. ANTHEM
is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield
Association. Life and Disability products underwritten by Anthem Life Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association. ANTHEM
is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield
Association.
SG_OHIX_ME_CF (1/18)
ME_SG_CFAPP-A 1/18
Page 1 of 6
Employee Change Form
For 1-50 Employee Small Groups
Maine
Instructions:
If you are cancelling coverage for a dependent or changing a name, please provide a reason in the designated sections. Complete electronically or in
black ink and return to your employer. Please use extra sheets of paper if necessary. NOTE: Some changes may be made by accessing anthem.com.
Section A: General Information
Employer name
Group no.
Employee last name
Employee first name
M.I.
Employee Social Security no.* (required)
Section B: Employee Information — Required
Reason for change –Required. Check all that apply.
o
Address change
o
Add spouse or Domestic Partner or dependent
o
Enrollment in Medicare (Fill in Section E)
o
o
o
Name change
Cancel spouse or Domestic Partner or dependent
Cancel coverage
o
o
o
Benefit change
Change Primary Care Physician (PCP)
Other:____________________________
o
Change Life and or Disability classification from _______to______
Event reason-Required. Check all that apply.
o
o
o
o
o
Add
Open enrollment (not applicable for life and disability products)
Marriage
Birth of child
Adoption of child
o
Change
o
Involuntary loss of coverage
o
Other insurance
o
Death
o
Divorce
o
o
Cancel
Other- please explain: _____________________________________________________________________________
Event date/Requested effective date- Required __________/______/_________ (MM/DD/YYYY)
Home address — Street and PO Box if applicable
City
State
ZIP code:
County
Birthdate (MM/DD/YYYY)
Sex
Marital status
o
Male
o
Female
o
Single
o
Married
o
Domestic Partner
Primary phone no.
Secondary phone no.
Email address
o
o
Primary Care Physician (PCP) name
PCP ID no.
Existing Patient?
Yes
No
PCP address
Section C: Family Information — Spouse and dependents to be added/changed/cancelled. Attach a separate sheet if necessary.
Event reason-Required. Check all that apply.
o
Add
o
o
o
o
o
Open enrollment (not applicable for Life and Disability)
Marriage
Birth of child
Adoption of child
Divorce
o
Change
o
Involuntary loss of coverage
o
Other insurance
o
Death
o
Other- please explain: ________________________________
o
Cancel
Event date/Requested effective date- Required __________/______/_________ (MM/DD/YYYY)
Spouse/Domestic Partner last name
First name
M.l.
Social Security
no.*(required)
Sex
Disabled?
Birthdate (MM/DD/YYYY)
Relationship to applicant
o
Male
o
Female
o
Yes
o
No
o
Spouse
o
Domestic Partner
PCP Name
PCP ID no.
Existing patient?
o
o
Yes
No
PCP Address
o
o
Does the Spouse/Domestic Partner have a different address?
Yes
No
If yes, please enter: ____________________________________________________________________________________________________
*Anthem Blue Cross and Blue Shield (Anthem) is required by the Internal Revenue Service to collect this information.
Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Maine, Inc. Independent licensee of the Blue Cross and Blue Shield Association. ANTHEM
is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield
Association. Life and Disability products underwritten by Anthem Life Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association. ANTHEM
is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield
Association.
SG_OHIX_ME_CF (1/18)
ME_SG_CFAPP-A 1/18
Page 1 of 6
Employee Name
Employee Health Plan ID no.
Section C: Family Information — Continued
Event reason-Required. Check all that apply.
o
Add
o
o
o
o
o
Open enrollment (not applicable for Life and Disability)
Marriage
Birth of child
Adoption of child
Divorce
o
Change
o
Involuntary loss of coverage
o
Other insurance
o
Death
o
Other- please explain: ________________________________
o
Cancel
Event date/Requested effective date- Required __________/______/_________ (MM/DD/YYYY)
Dependent last name
First name
M.l.
Social Security no.*(required)
Sex
Disabled?
Birthdate (MM/DD/YYYY)
Relationship to applicant
oMale
o
o
o
o
o
Female
Yes
No
Child
Other If other, what is relationship? ______________________
PCP Name
PCP ID no.
Existing patient?
o
Yes
o
No
PCP Address
o
o
Does this dependent have a different address?
Yes
No
If yes, please enter: ____________________________________________________________________________________________________
Event reason-Required. Check all that apply.
o
Add
o
o
o
o
o
Open enrollment (not applicable for Life and Disability)
Marriage
Birth of child
Adoption of child
Divorce
o
Change
o
Involuntary loss of coverage
o
Other insurance
o
Death
o
Other- please explain: ________________________________
o
Cancel
Event date/Requested effective date- Required __________/______/_________ (MM/DD/YYYY)
Dependent last name
First name
M.l.
Social Security no.*(required)
Sex
Disabled?
Birthdate (MM/DD/YYYY)
Relationship to applicant
oMale
o
o
o
o
o
Female
Yes
No
Child
Other If other, what is relationship? ______________________
PCP Name
PCP ID no.
Existing patient?
o
Yes
o
No
PCP Address
o
o
Does this dependent have a different address?
Yes
No
If yes, please enter: ____________________________________________________________________________________________________
Event reason-Required. Check all that apply.
o
Add
o
o
o
o
o
Open enrollment (not applicable for Life and Disability)
Marriage
Birth of child
Adoption of child
Divorce
o
Change
o
o
o
o
Involuntary loss of coverage
Other insurance
Death
Other- please explain: ________________________________
o
Cancel
Event date/Requested effective date- Required __________/______/_________ (MM/DD/YYYY)
First name
M.l.
Social Security no.*(required)
Dependent last name
Sex
Disabled?
Birthdate (MM/DD/YYYY)
Relationship to applicant
oMale
o
Female
o
Yes
o
No
o
Child
o
Other If other, what is relationship? ______________________
PCP Name
PCP ID no.
Existing patient?
o
o
Yes
No
PCP Address
o
o
Does this dependent have a different address?
Yes
No
If yes, please enter: ____________________________________________________________________________________________________
*Anthem is required by the Internal Revenue Service to collect this information.
SG_OHIX_ME_CF (1/18)
ME_SG_CFAPP-A 1/18
Page 2 of 6
Employee Name
Employee Health Plan ID no.
Section D: Plan/Type of Coverage
1. Medical Coverage
Enter network name, product plan name and contract code selected:
Network name
Product plan name
Contract code, if known
Note for Health Savings Account (HSA) enrollees:
If you enroll in an HSA plan, Anthem will facilitate the opening of a Health Savings Plan in your name, if directed by your employer.
Notice: There are hospitals, health care facilities, physicians or other health care providers who are not included in this plan’s network. Your financial
responsibilities for payment of covered services may differ if you use a network provider or a non-network provider. Please refer to the online
provider directory available at anthem.com to determine if a particular provider is in the network, or contact customer service for assistance.
o
o
Member medical coverage — select one:
Employee only
Employee + Spouse/Domestic Partner
o
o
Employee + child(ren)
Family
2. Dental Coverage
Product plan name
Contract code, if known
Member dental coverage — select one:
o
Employee only
o
Employee + Spouse/Domestic Partner
o
o
Employee + child(ren)
Family
3. Vision Coverage
Contract code, if known
o
I am enrolling in my Employer’s vision plan, if any.
o
Employee only
o
Employee + Spouse/Domestic Partner
Member vision coverage — select one:
o
o
Employee + child(ren)
Family
4. Life and Disability Coverage
o
I am enrolling in my Employer’s Life and/or Disability plan(s), if any
o
Basic Life and AD&D
o
Short Term Disability
o
o
Basic Dependent Life
Long Term Disability
o
Optional Supplemental/Voluntary Life and AD&D
$ ______ (employee amount)
o
Voluntary Short Term Disability
o
o
Optional Supplemental/Voluntary Dependent Life Spouse
$ ______ (spouse amount)
Voluntary Long Term Disability
o
Optional Supplemental/Voluntary Dependent Life Child
$ ______ (child amount)
Current annual income
Occupation
Life and Disability class no.
Primary Beneficiary- Attach a separate sheet if necessary
Last name
First name
M.l.
Relationship
Social Security no.
Percentage
Last name
First name
M.l.
Relationship
Social Security no.
Percentage
Contingent Beneficiary- Attach a separate sheet if necessary
Last name
First name
M.l.
Relationship
Social Security no.
Percentage
Last name
First name
M.l.
Relationship
Social Security no.
Percentage
Total percentages should add up to 100%. If no percentages are indicated, the proceeds will be divided equally. If no Primary beneficiary survives,
the proceeds will be paid to the contingent beneficiary(ies) listed above.
Spousal/Domestic Partner Consent for Community Property States Only (Note: The insurance company is not responsible for the validity of a
Spouse's/Domestic Partner’s consent for designation.) If you live in a community property state (AZ, CA, ID, LA, NM, NV,TX, WA and WI), your state
may require you to obtain the signature of your Spouse/Domestic Partner if your Spouse/Domestic Partner will not be named as a primary
beneficiary for 50% or more of your benefit amount. Please have your Spouse/Domestic Partner read and sign the following. I am aware that my
Spouse/Domestic Partner, the Employee/Retiree named above, has designated someone other than me to be the beneficiary of group life insurance
under the above policy. I hereby consent to such designation and waive any rights I may have to the proceeds of such insurance under applicable
community property laws. I understand that this consent and waiver supersedes any prior Spousal/Domestic Partner consent or waiver under this
plan.
Spouse/Domestic Partner Signature
Spouse/Domestic Partner name
Date (MM/DD/YYYY)
X
SG_OHIX_ME_CF (1/18)
ME_SG_CFAPP-A 1/18
Page 3 of 6
Employee Name
Employee Health Plan ID no.
Section E: Other Group Coverage
o
o
Are you or anyone applying for coverage currently eligible for Medicare?
Yes
No
If yes, give name: ________________________________________________________________________________________________________
Medicare ID no.
Part A effective date
Part B effective date
Medicare eligibility reason (check all that apply)
o
o
Age
Disability
o
ESRD: Onset date:
Medicare Part D ID no.
Medicare Part D Carrier
Part D effective date
On the day your coverage begins, will you or a family member be covered by other health coverage?
o
Yes
o
No
If yes to any of these questions, please provide the following.
Coverage
Name of person covered
Type
(check all that
Carrier phone
Dates
(Last name, first, M.l.)
(check one)
apply)
Carrier name
no.
Policy ID no.
(if applicable)
o
Individual
o
Health
Start: ____/_____/______
o
o
Group
Dental
End: ____/_____/______
o
Orthodontia
o
o
Individual
Health
Start: ____/_____/______
o
Group
o
Dental
End: ____/_____/______
o
Orthodontia
o
o
Individual
Health
Start: ____/_____/______
o
Group
o
Dental
End: ____/_____/______
o
Orthodontia
o
o
Individual
Health
Start: ____/_____/______
o
o
Group
Dental
End: ____/_____/______
o
Orthodontia
Section F: Terms, Conditions and Authorizations
Please read this section carefully before signing the application.
Eligible employee:
An active employee of the Employer who works the number of hours per week to be eligible for benefits as defined by the Employer and
·
approved by Anthem Blue Cross and Blue Shield (Anthem) as of the effective date. Employment must be verifiable from state or federal wage tax
reports.
An employee, as defined above, who enters into employment after the coverage effective date and who completes the group imposed waiting
·
period for eligibility (if any) and applies for coverage within 30 days.
·
Any other class of persons identified by the Employer, provided that written approval of their eligibility is obtained from the Company(ies); or
Employees eligible for continuous coverage under state or federal laws.
·
Eligible employee does not include independent contractors (whose compensation is reported on IRS Form 1099) and directors and officers of the
Group Policyholder if they do not work the required number of hours per week described above.
Eligible dependent:
·
Employee's spouse, eligible domestic partner, or children age 26 or younger, which includes a newborn, natural child, or a child placed with the
employee for adoption, a stepchild or any other child for whom the employee has legal guardianship or court ordered custody. The age limit for
enrolling a child is age 26. Coverage for children will end on the last day of the month in which the children reach age 26.
·
The age limit of 26 does not apply for continued enrollment of an unmarried child who is mentally or physically disabled. The disability must have
begun before the child’s 26th birthday, and the child must have been covered by us on and continuously since his or her 26th birthday.
Dependents eligible for continuous coverage under state or federal laws.
·
As an eligible employee, I am requesting coverage for myself and all eligible dependents listed and authorize my employer to deduct any required
contributions for this insurance from my earnings. All statements and answers I have given are true and complete. I understand it is a crime to
knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may
include imprisonment, fines or a denial of insurance benefits. I understand all benefits are subject to conditions stated in the Group Contract and
coverage document.
SG_OHIX_ME_CF (1/18)
ME_SG_CFAPP-A 1/18
Page 4 of 6
Employee Name
Employee Health Plan ID no.
In signing this application I represent that:
I certify each Social Security number listed on this application is correct.
I have read or have had read to me the completed application, and I realize any false statement or misrepresentation in the application may result in
loss of coverage.
I’m signing here because I want to get information about my benefits by email or electronically. This may include my certificate or evidence of
coverage, explanation of benefits statements, required notices and helpful or personalized information to get the most out of my plan, so I will make
sure Anthem has my most up to date email. These electronic communications may include specific details about me and my plan. I know I can
change my mind at any time or request a free copy of specific materials by mail. I’ll just contact Anthem to do either.
For Health Savings Account enrollees: Except as otherwise provided in any agreement between me and the financial custodian, the custodian of my
Health Savings Account (HSA), I understand that my authorization is required before the financial custodian may provide Anthem with information
regarding my HSA. I hereby authorize the financial custodian to provide Anthem with information about my HSA, including account number, account
balance and information regarding account activity. I also understand that I may provide Anthem with a written request to revoke my authorization at
any time.
My signature on this application constitutes my approval and authorization for Anthem Blue Cross and Blue Shield to enforce its subrogation rights for
my claims on a just and equitable basis.
Important Information: If you’re purchasing coverage that provides dental or vision benefits only please review your certificate of coverage carefully.
Life and/or Disability Authorization Section – Read carefully before signing.
1. I authorize the release of any medical records or information concerning claims, conditions or treatment of myself and for any dependents listed
herein, by any provider of health services, pharmacy related service organization, medical or medically-related facility, or the MIB, Inc., to
Anthem, its affiliates, and any administrators, reinsurers, agents, or other entity providing services on behalf of Anthem. This information will be
used for purposes which mean: processing this application for enrollment; group risk classification; detecting or preventing fraud or
misrepresentation; internal and external audits; administration of claims; and quality improvement programs. Anthem will advise such entities that
such information must be kept confidential to the extent necessary or as otherwise provided by law, and should not be used for any unlawful
purpose. This information includes any records or knowledge about medical history, including sensitive services which mean mental health,
psychiatric, substance abuse, reproductive health, AIDS, sexually transmitted or other communicable diseases contained in such records,
including, all records of office visits, examinations, treatment, evaluation, diagnostic and laboratory testing, reports, consultations, hospital
records, prescription history, records for treatment of substance abuse, psychiatric counseling, notes, correspondence, insurance and billing
information for treatment or services rendered by any provider. I understand that Anthem may collect personal information about me from court
records, state agencies, and professional investigative services regarding illegal activities, and that both personal and privileged information may
be collected and disclosed to MIB, Inc. or the reinsurer without my further authorization, and may no longer be protected by Federal privacy laws.
I also understand that I have a right to see and correct personal information that Anthem collects about me, and that I may receive a more
detailed description of my rights under this law by writing to Anthem. This authorization excludes disclosure of the result of a test for HIV if the
applicant has not developed symptoms of the disease AIDS or ARC. Such test results shall not be discovered or published. Nothing in this
caveat will prohibit this authorization from including the fact that the applicant has AIDS or ARC.
2. Payment of proceeds shall be made in accordance with the terms of the group contract. Unless otherwise provided herein, if one or more life
insurance beneficiaries are named, the proceeds due shall be paid in equal shares to the named beneficiaries surviving the insured. Beneficiaries
may be changed by the insured employee’s written notice to his or her employer.
3. These coverages will become effective on the date established by the provisions of the group contract and certificates issued thereunder.
4. Failure to sign this Authorization may impair the ability of Anthem Life Insurance Company to evaluate or process the application and may be a
basis for denying coverage or denying a claim. This Authorization may be revoked at any time by the Applicant sending a written revocation to us
at: Anthem, Revocation Department, PO Box 182361, Columbus, OH, 43218-2361. Such revocation must be signed and dated by the Applicant
and spouse/domestic partner, if the spouse/domestic partner is to be covered. Revocation of this Authorization may result in denial of coverage or
denial of claim. The Applicant is entitled to receive a copy of this Authorization.
I give this authorization for myself and on behalf of my eligible dependents if covered by the Plan, including my Spouse/Domestic Partner unless
he/she signs below. I am acting as their agent and representative. This authorization, for purposes of processing this enrollment form, is valid for a
period of 30 months from the date signed unless revoked by me in writing, which I may do at any time by contacting Anthem. A photocopy is as valid
as the original.
SG_OHIX_ME_CF (1/18)
ME_SG_CFAPP-A 1/18
Page 5 of 6
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