Employee change form
- 1. Existing Patient: Hourly Salary Open Enrollment I am Refusing all Health Coverage at this time. I understand that if I decide to apply later coverage may not be available until the next open or special enrollment period. Ethnicity optional Check all that apply. Relation to You In addition to this policy, do you or your dependents have any other insurance coverage (including BCBSF plans) that will be in effect after this coverage begins? Yes No BCBSF Contract # Medicare # Pharmacy/Medicare D # BlueCare (HMO) Plan # Please type or write clearly in black or blue ink. Health Enrollment Application Section B: Employee Information Section C: Coverage Level and Plan Information Section E: Other Health Insurance Information This section must be completed for claims processing and Prior Coverage Information Effective Date of Coverage: Location #: Work Status: Employee #: Social Security #: Social Security Number: Prior Heath Carrier Name: Prior Employee Hire Date: 22095 0210R SR List names of all family members that were covered, including yourself: Last Name: First Name: M.I.: Street Address: Complete the following only if this is the first time you or your dependents: (1) are enrolling for health insurance with this employer; (2) currently have health coverage; and/or (3) have any health coverage in the past 12 months that this coverage replaces OR you can attach a Certificate of Creditable Coverage. Apt. #: City: State: County: Marital Status: Retirement Date: Paid: Job Title: Sex: M F Legally Separated Ethnicity optional Check all that apply: Employee Health Coverage: *When available BlueOptions Plan # Date of Hire: Birth Date: Birth Date: * If you indicated "O" in “Relation to You” above for any dependents, please explain here: List the name of each dependent listed above that is married or has dependent child(ren) or lives outside of Florida. Zip: Phone: BlueChoice (PPO) Plan # Language of Preference: optional - for data collection purposes only Physician Name / ID # HMO only: Last Name: (if different than employee) First Name, M.I. You Support Existing Patient (Y/N) Lives With You Is a Student Sex (M or F) Spouse (S) Child (C) Other (O)* Dependent Physician Name/ID HMO only A B C H N W A B C H N W A B C H N W A B C H N W A) Asian/Pacific Islander B) Black/African American C) Caribbean Islander H) Hispanic N) Native American W) White Contract #: Cancel Date: Effective Date: Signature: Date: Section D: Dependent Information Attach separate sheet, if additional space is needed, with dependent information, sign & date. Other Plan # BlueSelect Plan # Check if Disabled Miami-Dade Blue Plan # Yes No English Spanish Other Prefer not to answer Employee *Employee & Spouse *Employee & One Dependent *Employee &Child(ren) Family Single Married Divorced Widowed Actively at Work Cobra Retired Asian/Pacific Islander Black/African American Caribbean Islander Hispanic Native American White Signature: Date: I understand that any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. MyBasic Plan # SectionA: Current Information Group Name: Group #: Division #: Package #: