> endobj 956 0 obj <>/AcroForm 1058 0 R/Lang(�f6Y�����5� �! 2020 Small Group Enrollment Application/Change Form Use this form to … Complete the form and return it to us within 30 days of the change. 9/16 Anthem Blue Cross and Blue Shield is the trade name of: In Indiana: Anthem Insurance Companies, Inc. File is in portable document format (PDF). Change Form. Submit clear black-and-white copies of these items to Blue Cross with a letter explaining your request. The purpose of this form is to help members of an employer-sponsored insurance plan update us when they have any changes to their status such as: Please contact your employer to see if you need to update your address or policy information with them first before filling out the Change of Status form. Home Office 4000 House Ave. ... An independent licensee of the Blue Cross and Blue Shield Association. Home Office 4000 House Ave. You might not be able to log in from 2 to 4 a.m. Jan. 9 while we work on the website. Newborn and adopted child change form [pdf] 2. (Please check the appropriate boxes and complete only those State and Federal Privacy laws prohibit unauthorized access to Member's private information. It is not an application for coverage. Legal Name 2. Blue Cross Blue Shield of Arizona Provider Change Form NOTE re address changes: If BCBSAZ does not receive a new address from the provider in writing, BCBSAZ will continue sending correspondence, including claims payments, to the address currently listed in BCBSAZ’s system. Thank you for being a part of the Anthem network of health care professionals! These companies are Independent Licensees of the Blue Cross and Blue Shield Association. Anthem Blue Cross and Blue Shield Agent of Record (AOR) Change Form 49655CEMENABS Rev. Unsupported browser. If you need to change existing demographic information, complete the Demographic Change Form . If you have completed a Demographic Change Form, you can check the status of your application by entering the case number you received in your confirmation email in our Case Status Checker.Examples of information you can change include: 1. [u�&l�1���K�rQ{ifz]�Vd6x)����[��/�D��C� .5G endstream endobj startxref 0 %%EOF 1250 0 obj <>stream First Name MI. We apologize for the inconvenience. The forms in this online library are updated frequently—check often to ensure you are using the most current versions.Some of these documents are available as PDF files. Complete GROUP ENROLLMENT/CHANGE FORM - Blue Cross Blue Shield online with US Legal Forms. 610I P.O. You might not be able to log in or access some applications from 2 to 6 a.m. Jan. 9 while we work on the website. 2) Telephone Number- The employer’s telephone number. To view this file, you may need to install a PDF reader program. ... SM1 Mark of Blue Cross and Blue Shield of North Carolina. Name Change. Last Name * Group Number * Subscriber ID * Email * Change this, "OLD" information... Street Address (OLD) * ... Blue Cross and Blue Shield of Vermont is an Independent Licensee of the Blue Cross and Blue Shield Association. Name of Plan Effective Date of Membership Change ... please fill out the Affidavit of Domestic Partnership for Benefits Eligibility form in addition to this form. 29-462 12/19 An independent licensee of the Blue Cross Blue Shield Association. If any of these changes result in a change on your W-9, you must submit a copy of your W-9 with this change form. Individuals attempting unauthorized access will be prosecuted. ... SM1 Mark of Blue Cross and Blue Shield of North Carolina. Vision change form [pdf] Fill in your PCP's information and mail the completed form to BCBSNM. Blue Care Network Name Change. employer to sign and mail to Blue Cross Blue Shield of Massachusetts. Information Change Request. There are three sections to this form – subscriber information, coordination of benefits information and health savings and flexible spending account options. h���; Change Address/Name: Complete Section 1 and check the “Other Change(s)” box; then, complete Sections 2 and 9. Enrollment Change Request Form These forms should be used by current Blue Medicare HMO and PPO members to enroll in different Blue Medicare HMO and Blue Medicare PPO plans. Blue Cross Blue Shield of Michigan Employee SSN Correction. Section 1– Applicant Information. Box 5043 Important Legal and Privacy Information | Important Information About Medicare Plans | Privacy Practices Address/Telephone Number Change. Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Virginia, Inc. Anthem Blue Cross and Blue Shield and its affiliated HMOs, HealthKeepers, Inc., Peninsula Health Care, Inc., 170006 (4/04) and Priority Health Care, Inc. are independent licensees of the Blue Cross and Blue Shield … Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association. Be sure your letter includes your name, address, and member ID number. Please provide ALL applicable information to avoid delays. ® Registered marks of the Blue Cross and Blue Shield Association. Page 1. Blue Cross Blue Shield of Arizona Provider Change Form NOTE re address changes: If BCBSAZ does not receive a new address from the provider in writing, BCBSAZ will continue sending correspondence, including claims payments, to the address currently listed in BCBSAZ’s system. PAGE 1 of 2 F110, 4/16. 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. for group coverage. 08/2019. Section 1– Applicant Information (completion of this section is required) Check this box if applicant information has changed. Forms and Documents. "I had a vision to bring these best practices together to create the nation's best health care company," says Samitt of joining Blue Cross. Or you can download and save the form, to review and sign at a later date. Forms and Documents. Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Virginia, Inc. 170006 (06/11) Anthem Blue Cross and Blue Shield and its affiliated HMO, HealthKeepers, Inc., are independent licensees of the Blue Cross and Blue Shield Association. Notify us of a name change Claim forms Health Services Claim form (ABC 20039) This form is used to submit claims for products or services such as prescription drugs, private or semi-private hospital accommodation, ambulance, psychology services, physiotherapy, chiropractic, wheelchairs, vision care and hearing aids. SECTION 5 A dependent child who is medically certified as disabled and dependent upon the member or his/her spouse*** or domestic partner (provided the group You can also fax it to the number listed on the form Current practice information* Group practice name: Group practice NPI number: Blue Cross and Blue Shield of Louisiana and its subsidiaries, HMO Louisiana, Inc. and Southern National Life Insurance Company, Inc., comply with applicable federal civil rights laws and do not exclude people or treat them differently on the basis of race, color, national origin, age, disability or sex. 2020 Individual Health Plan Application/Change in Coverage (Off Exchange)  Use this form to apply for a BCBSMT Individual Health Plan (Off Exchange) or to submit a change in coverage. Easily fill out PDF blank, edit, and sign them. Changes will be effective within 45 days. BCBSAZ will not be responsible for lost or returned mail if we do not 300 P.O. If the change is due to a change in ownership, please contact your agent or marketing representative for details on how to proceed. ®*The Blue Cross symbol and name, Colour of Caring and mybluecross are registered marks of the Canadian Association of Blue Cross Plans, independently licensed by Manitoba Blue Cross. To review and sign your request now electronically, select the sign now option below. Add/Remove Dependent. To … "To be an innovator, a disruptive change agent and a benchmark for excellence both here in our community and in the nation." Site Map | Feedback | Download Adobe Acrobat Reader, Learn more about a Healthier Michigan.org, Change of Status Form for group plans (PDF), How to keep your coverage accurate and up to date, Important Information About Medicare Plans, Health savings and flexible spending account changes. independent licensees of the Blue Cross and Blue Shield Association. Please use the check box to identify your change … Filter by form type Employer Forms. forms The back of your ID card states if you are insured through Wellmark BCBS of Iowa, Wellmark Health Plan of Iowa, or Wellmark BCBS of South Dakota. Send completed forms to: (For Blue Cross Blue Shield of Michigan) Blue Cross Blue Shield of Michigan Membership and Billing – M.C. In the District of Columbia and Maryland, CareFirst MedPlus is the business name of First Care, Inc. request, your employer is required to sign the application. Register Now. Telligent is an operating division of Verint Americas, Inc., an independent company that provides and hosts an online community platform for blogging and access to social media for Blue Cross and Blue Shield of Texas. This form cannot be used for primary care physician (PCP) changes – subscriber must call the Member Services phone number on the back of their ID card. Here are some commonly used forms for conducting business with Blue Cross and Blue Shield of Oklahoma (BCBSOK). Just browse through this list and select the appropriate link to download a PDF version of the form. You can also fax it to the number listed on the form We apologize for the inconvenience. Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Virginia, Inc. Anthem Blue Cross and Blue Shield and its affiliated HMOs, HealthKeepers, Inc., Peninsula Health Care, Inc., 170006 (4/04) and Priority Health Care, Inc. are independent licensees of the Blue Cross and Blue Shield … Insurance products issued by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148. If so, we can help you make the most of your benefits—and possibly save you money! %PDF-1.6 %���� Send your letter to: Blue Cross & Blue Shield of Rhode Island Attn: Claims Department 500 Exchange Street Providence, RI 02903 Save or instantly send your ready documents. Provider File Update; As you know, changes to provider file information are required by your contract. Just click on a form, print the form, and fill it out. 610G Health and vision insurance is offered by Blue Cross and Blue Shield of Florida, Inc., D/B/A Florida Blue. Choose the form based on the state you're insured through, regardless of where services were received. Use these forms to request a change to your current policy, such as name changes, deductible amounts, dependent status and more. \\G�V���\n\nO> �. You may fax or mail the form to. You can email your form to eesdrafts@arkbluecross.com or mail it to Arkansas Blue Cross and Blue Shield, EES Membership Financial, P.O. Submit clear black-and-white copies of these items to Blue Cross with a letter explaining your request. Dr. Samitt now brings that extensive knowledge and experience to Blue Cross. 29-151 02/19 An independent licensee of the Blue Cross Blue Shield Association. ... You have the right to authorize Arkansas Blue Cross Blue Shield to disclose information regarding claims, payments or … Telligent is an operating division of Verint Americas, Inc., an independent company that provides and hosts an online community platform for blogging and access to social media for Blue Cross and Blue Shield of Illinois. First Name MI. 1) Employer Name- The employer’s name. Download Form: Change Notification Form: Complete this form if your name changes through marriage or other event, or if your mailing address changes. A: Blue Cross Blue Shield of Nebraska is required to report certain member information each year to the IRS, which includes: Name, Address, and Tax Identification Number (TIN) of the contract holder [Your Social Security Number (SSN) is commonly used as your TIN.] Box 2260 . Use the Provider Maintenance Form (PMF) to submit changes or additions to your information. Page 1 Change Form for First Choice coverage Section 1 – Applicant Information First Name MI Last Name Suffix Residential Address City State ZIP Code +4 County Mailing Address (if … Send your letter to: Blue Cross & Blue Shield of Rhode Island Attn: Claims Department 500 Exchange Street Providence, RI 02903 Blue Cross and Blue Shield of Illinois is the trade name of Dearborn Life Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association. for First Choice coverage. Get access to your member portal. Rev. Form: Purpose: Download/ complete online: Refusal of Coverage (C19927) This form should be completed and submitted when eligible employees are refusing the employer's Blue Shield of California/Blue Shield of California Life & Health Insurance Company health plan coverage for themselves and/or their spouse, domestic partner, or dependent(s) if applicable. In Section 4, please include enrollee’s or dependent’s name, social security number, date of birth, and name and number of the new PCP. BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield … If you're a Blue Cross Blue Shield of Michigan or Blue Care Network member and you have coverage through your employer, use this form to let us know of any changes to your status, like address or name changes. To order additional forms, call 1-800-450-0962. Here are some commonly used forms you need for Blue Cross and Blue Shield of Montana (BCBSMT) program enrollment, account maintenance, supplies and more. Box 2260 Refer to Demographic Change Form User Guide. Simply complete this form and mail to: Attn: OCL Department (A) - 00119 Blue Cross & Blue Shield of Rhode Island 500 Exchange Street Providence, RI 02903-2699 An Independent Licensee of the Blue Cross and Blue Shield Association HOW TO COMPLETE YOUR MEMBER CHANGE FORM Complete the following fields on the Member Change Form. Incomplete change forms or forms without an authorizing signature will not be processed. Changes are not immediate upon submission. Download claim forms, applications, and more. �L|����3��i�+c���:;�x���O���ݕ�e�V�Yn�}է�-��*�\�k�>��܆舠V�X;����X����8�m ���}A|���d��̻����ص���XNM�ˮ:��2~ߵ%�XAd` |w�>/t����j��4rI��E��F]�R, 2��@�6�U�&`]��x����e� =��u6��\�x�u���B�"�u��/�ˌ��Eq@�ϻ�g f���2����aL�3�5�W^�B��+���ޠ�����K�Zg��:�g����Mu%zgrH�j�P�hת���X���Z,�u�QM� p2�1 jf�1��'��� ���x�#w2�Y��x�R��% De Blue Cross with a letter explaining your request s Telephone number for Group Plans Who this! 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The purpose of this form is to help members of an employer-sponsored insurance plan update us when they have any changes to their status such as: Please contact your employer to see if you need to update your address or policy information with them first before filling out the Change of Status form. Home Office 4000 House Ave. ... An independent licensee of the Blue Cross and Blue Shield Association. Home Office 4000 House Ave. You might not be able to log in from 2 to 4 a.m. Jan. 9 while we work on the website. Newborn and adopted child change form [pdf] 2. (Please check the appropriate boxes and complete only those State and Federal Privacy laws prohibit unauthorized access to Member's private information. It is not an application for coverage. Legal Name 2. Blue Cross Blue Shield of Arizona Provider Change Form NOTE re address changes: If BCBSAZ does not receive a new address from the provider in writing, BCBSAZ will continue sending correspondence, including claims payments, to the address currently listed in BCBSAZ’s system. Thank you for being a part of the Anthem network of health care professionals! These companies are Independent Licensees of the Blue Cross and Blue Shield Association. Anthem Blue Cross and Blue Shield Agent of Record (AOR) Change Form 49655CEMENABS Rev. Unsupported browser. If you need to change existing demographic information, complete the Demographic Change Form . If you have completed a Demographic Change Form, you can check the status of your application by entering the case number you received in your confirmation email in our Case Status Checker.Examples of information you can change include: 1. [u�&l�1���K�rQ{ifz]�Vd6x)����[��/�D��C� .5G endstream endobj startxref 0 %%EOF 1250 0 obj <>stream First Name MI. We apologize for the inconvenience. The forms in this online library are updated frequently—check often to ensure you are using the most current versions.Some of these documents are available as PDF files. Complete GROUP ENROLLMENT/CHANGE FORM - Blue Cross Blue Shield online with US Legal Forms. 610I P.O. You might not be able to log in or access some applications from 2 to 6 a.m. Jan. 9 while we work on the website. 2) Telephone Number- The employer’s telephone number. To view this file, you may need to install a PDF reader program. ... SM1 Mark of Blue Cross and Blue Shield of North Carolina. Name Change. Last Name * Group Number * Subscriber ID * Email * Change this, "OLD" information... Street Address (OLD) * ... Blue Cross and Blue Shield of Vermont is an Independent Licensee of the Blue Cross and Blue Shield Association. Name of Plan Effective Date of Membership Change ... please fill out the Affidavit of Domestic Partnership for Benefits Eligibility form in addition to this form. 29-462 12/19 An independent licensee of the Blue Cross Blue Shield Association. If any of these changes result in a change on your W-9, you must submit a copy of your W-9 with this change form. Individuals attempting unauthorized access will be prosecuted. ... SM1 Mark of Blue Cross and Blue Shield of North Carolina. Vision change form [pdf] Fill in your PCP's information and mail the completed form to BCBSNM. Blue Care Network Name Change. employer to sign and mail to Blue Cross Blue Shield of Massachusetts. Information Change Request. There are three sections to this form – subscriber information, coordination of benefits information and health savings and flexible spending account options. h���; Change Address/Name: Complete Section 1 and check the “Other Change(s)” box; then, complete Sections 2 and 9. Enrollment Change Request Form These forms should be used by current Blue Medicare HMO and PPO members to enroll in different Blue Medicare HMO and Blue Medicare PPO plans. Blue Cross Blue Shield of Michigan Employee SSN Correction. Section 1– Applicant Information. Box 5043 Important Legal and Privacy Information | Important Information About Medicare Plans | Privacy Practices Address/Telephone Number Change. Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Virginia, Inc. Anthem Blue Cross and Blue Shield and its affiliated HMOs, HealthKeepers, Inc., Peninsula Health Care, Inc., 170006 (4/04) and Priority Health Care, Inc. are independent licensees of the Blue Cross and Blue Shield … Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association. Be sure your letter includes your name, address, and member ID number. Please provide ALL applicable information to avoid delays. ® Registered marks of the Blue Cross and Blue Shield Association. Page 1. Blue Cross Blue Shield of Arizona Provider Change Form NOTE re address changes: If BCBSAZ does not receive a new address from the provider in writing, BCBSAZ will continue sending correspondence, including claims payments, to the address currently listed in BCBSAZ’s system. PAGE 1 of 2 F110, 4/16. 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. for group coverage. 08/2019. Section 1– Applicant Information (completion of this section is required) Check this box if applicant information has changed. Forms and Documents. "I had a vision to bring these best practices together to create the nation's best health care company," says Samitt of joining Blue Cross. Or you can download and save the form, to review and sign at a later date. Forms and Documents. Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Virginia, Inc. 170006 (06/11) Anthem Blue Cross and Blue Shield and its affiliated HMO, HealthKeepers, Inc., are independent licensees of the Blue Cross and Blue Shield Association. Notify us of a name change Claim forms Health Services Claim form (ABC 20039) This form is used to submit claims for products or services such as prescription drugs, private or semi-private hospital accommodation, ambulance, psychology services, physiotherapy, chiropractic, wheelchairs, vision care and hearing aids. SECTION 5 A dependent child who is medically certified as disabled and dependent upon the member or his/her spouse*** or domestic partner (provided the group You can also fax it to the number listed on the form Current practice information* Group practice name: Group practice NPI number: Blue Cross and Blue Shield of Louisiana and its subsidiaries, HMO Louisiana, Inc. and Southern National Life Insurance Company, Inc., comply with applicable federal civil rights laws and do not exclude people or treat them differently on the basis of race, color, national origin, age, disability or sex. 2020 Individual Health Plan Application/Change in Coverage (Off Exchange)  Use this form to apply for a BCBSMT Individual Health Plan (Off Exchange) or to submit a change in coverage. Easily fill out PDF blank, edit, and sign them. Changes will be effective within 45 days. BCBSAZ will not be responsible for lost or returned mail if we do not 300 P.O. If the change is due to a change in ownership, please contact your agent or marketing representative for details on how to proceed. ®*The Blue Cross symbol and name, Colour of Caring and mybluecross are registered marks of the Canadian Association of Blue Cross Plans, independently licensed by Manitoba Blue Cross. To review and sign your request now electronically, select the sign now option below. Add/Remove Dependent. To … "To be an innovator, a disruptive change agent and a benchmark for excellence both here in our community and in the nation." Site Map | Feedback | Download Adobe Acrobat Reader, Learn more about a Healthier Michigan.org, Change of Status Form for group plans (PDF), How to keep your coverage accurate and up to date, Important Information About Medicare Plans, Health savings and flexible spending account changes. independent licensees of the Blue Cross and Blue Shield Association. Please use the check box to identify your change … Filter by form type Employer Forms. forms The back of your ID card states if you are insured through Wellmark BCBS of Iowa, Wellmark Health Plan of Iowa, or Wellmark BCBS of South Dakota. Send completed forms to: (For Blue Cross Blue Shield of Michigan) Blue Cross Blue Shield of Michigan Membership and Billing – M.C. In the District of Columbia and Maryland, CareFirst MedPlus is the business name of First Care, Inc. request, your employer is required to sign the application. Register Now. Telligent is an operating division of Verint Americas, Inc., an independent company that provides and hosts an online community platform for blogging and access to social media for Blue Cross and Blue Shield of Texas. This form cannot be used for primary care physician (PCP) changes – subscriber must call the Member Services phone number on the back of their ID card. Here are some commonly used forms for conducting business with Blue Cross and Blue Shield of Oklahoma (BCBSOK). Just browse through this list and select the appropriate link to download a PDF version of the form. You can also fax it to the number listed on the form We apologize for the inconvenience. Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Virginia, Inc. Anthem Blue Cross and Blue Shield and its affiliated HMOs, HealthKeepers, Inc., Peninsula Health Care, Inc., 170006 (4/04) and Priority Health Care, Inc. are independent licensees of the Blue Cross and Blue Shield … Insurance products issued by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148. If so, we can help you make the most of your benefits—and possibly save you money! %PDF-1.6 %���� Send your letter to: Blue Cross & Blue Shield of Rhode Island Attn: Claims Department 500 Exchange Street Providence, RI 02903 Save or instantly send your ready documents. Provider File Update; As you know, changes to provider file information are required by your contract. Just click on a form, print the form, and fill it out. 610G Health and vision insurance is offered by Blue Cross and Blue Shield of Florida, Inc., D/B/A Florida Blue. Choose the form based on the state you're insured through, regardless of where services were received. Use these forms to request a change to your current policy, such as name changes, deductible amounts, dependent status and more. \\G�V���\n\nO> �. You may fax or mail the form to. You can email your form to eesdrafts@arkbluecross.com or mail it to Arkansas Blue Cross and Blue Shield, EES Membership Financial, P.O. Submit clear black-and-white copies of these items to Blue Cross with a letter explaining your request. Dr. Samitt now brings that extensive knowledge and experience to Blue Cross. 29-151 02/19 An independent licensee of the Blue Cross Blue Shield Association. ... You have the right to authorize Arkansas Blue Cross Blue Shield to disclose information regarding claims, payments or … Telligent is an operating division of Verint Americas, Inc., an independent company that provides and hosts an online community platform for blogging and access to social media for Blue Cross and Blue Shield of Illinois. First Name MI. 1) Employer Name- The employer’s name. Download Form: Change Notification Form: Complete this form if your name changes through marriage or other event, or if your mailing address changes. A: Blue Cross Blue Shield of Nebraska is required to report certain member information each year to the IRS, which includes: Name, Address, and Tax Identification Number (TIN) of the contract holder [Your Social Security Number (SSN) is commonly used as your TIN.] Box 2260 . Use the Provider Maintenance Form (PMF) to submit changes or additions to your information. Page 1 Change Form for First Choice coverage Section 1 – Applicant Information First Name MI Last Name Suffix Residential Address City State ZIP Code +4 County Mailing Address (if … Send your letter to: Blue Cross & Blue Shield of Rhode Island Attn: Claims Department 500 Exchange Street Providence, RI 02903 Blue Cross and Blue Shield of Illinois is the trade name of Dearborn Life Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association. for First Choice coverage. Get access to your member portal. Rev. Form: Purpose: Download/ complete online: Refusal of Coverage (C19927) This form should be completed and submitted when eligible employees are refusing the employer's Blue Shield of California/Blue Shield of California Life & Health Insurance Company health plan coverage for themselves and/or their spouse, domestic partner, or dependent(s) if applicable. In Section 4, please include enrollee’s or dependent’s name, social security number, date of birth, and name and number of the new PCP. BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield … If you're a Blue Cross Blue Shield of Michigan or Blue Care Network member and you have coverage through your employer, use this form to let us know of any changes to your status, like address or name changes. To order additional forms, call 1-800-450-0962. Here are some commonly used forms you need for Blue Cross and Blue Shield of Montana (BCBSMT) program enrollment, account maintenance, supplies and more. Box 2260 Refer to Demographic Change Form User Guide. Simply complete this form and mail to: Attn: OCL Department (A) - 00119 Blue Cross & Blue Shield of Rhode Island 500 Exchange Street Providence, RI 02903-2699 An Independent Licensee of the Blue Cross and Blue Shield Association HOW TO COMPLETE YOUR MEMBER CHANGE FORM Complete the following fields on the Member Change Form. Incomplete change forms or forms without an authorizing signature will not be processed. Changes are not immediate upon submission. Download claim forms, applications, and more. �L|����3��i�+c���:;�x���O���ݕ�e�V�Yn�}է�-��*�\�k�>��܆舠V�X;����X����8�m ���}A|���d��̻����ص���XNM�ˮ:��2~ߵ%�XAd` |w�>/t����j��4rI��E��F]�R, 2��@�6�U�&`]��x����e� =��u6��\�x�u���B�"�u��/�ˌ��Eq@�ϻ�g f���2����aL�3�5�W^�B��+���ޠ�����K�Zg��:�g����Mu%zgrH�j�P�hת���X���Z,�u�QM� p2�1 jf�1��'��� ���x�#w2�Y��x�R��% De Blue Cross with a letter explaining your request s Telephone number for Group Plans Who this! 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*†Blue Shield is a registered trade-mark of the Blue Cross Blue Shield Association. Independent licensee of the Blue Cross and Blue Shield Association. Changes will be effective within 45 days. In Section 1, check the “Other Change(s)” box, then complete sections 2, 3, 4 and 10. 6� �2���w��`_��pZ��LG�v������r&8�\=֑��̨u�� endstream endobj 955 0 obj <>>>/Filter/Standard/Length 128/O(�ĺ�'6|�S��"z1��:%�I i��I/c$��)/P -1052/R 4/StmF/StdCF/StrF/StdCF/U(�,����������}� )/V 4>> endobj 956 0 obj <>/AcroForm 1058 0 R/Lang(�f6Y�����5� �! 2020 Small Group Enrollment Application/Change Form Use this form to … Complete the form and return it to us within 30 days of the change. 9/16 Anthem Blue Cross and Blue Shield is the trade name of: In Indiana: Anthem Insurance Companies, Inc. File is in portable document format (PDF). Change Form. Submit clear black-and-white copies of these items to Blue Cross with a letter explaining your request. The purpose of this form is to help members of an employer-sponsored insurance plan update us when they have any changes to their status such as: Please contact your employer to see if you need to update your address or policy information with them first before filling out the Change of Status form. Home Office 4000 House Ave. ... An independent licensee of the Blue Cross and Blue Shield Association. Home Office 4000 House Ave. You might not be able to log in from 2 to 4 a.m. Jan. 9 while we work on the website. Newborn and adopted child change form [pdf] 2. (Please check the appropriate boxes and complete only those State and Federal Privacy laws prohibit unauthorized access to Member's private information. It is not an application for coverage. Legal Name 2. Blue Cross Blue Shield of Arizona Provider Change Form NOTE re address changes: If BCBSAZ does not receive a new address from the provider in writing, BCBSAZ will continue sending correspondence, including claims payments, to the address currently listed in BCBSAZ’s system. Thank you for being a part of the Anthem network of health care professionals! These companies are Independent Licensees of the Blue Cross and Blue Shield Association. Anthem Blue Cross and Blue Shield Agent of Record (AOR) Change Form 49655CEMENABS Rev. Unsupported browser. If you need to change existing demographic information, complete the Demographic Change Form . If you have completed a Demographic Change Form, you can check the status of your application by entering the case number you received in your confirmation email in our Case Status Checker.Examples of information you can change include: 1. [u�&l�1���K�rQ{ifz]�Vd6x)����[��/�D��C� .5G endstream endobj startxref 0 %%EOF 1250 0 obj <>stream First Name MI. We apologize for the inconvenience. The forms in this online library are updated frequently—check often to ensure you are using the most current versions.Some of these documents are available as PDF files. Complete GROUP ENROLLMENT/CHANGE FORM - Blue Cross Blue Shield online with US Legal Forms. 610I P.O. You might not be able to log in or access some applications from 2 to 6 a.m. Jan. 9 while we work on the website. 2) Telephone Number- The employer’s telephone number. To view this file, you may need to install a PDF reader program. ... SM1 Mark of Blue Cross and Blue Shield of North Carolina. Name Change. Last Name * Group Number * Subscriber ID * Email * Change this, "OLD" information... Street Address (OLD) * ... Blue Cross and Blue Shield of Vermont is an Independent Licensee of the Blue Cross and Blue Shield Association. Name of Plan Effective Date of Membership Change ... please fill out the Affidavit of Domestic Partnership for Benefits Eligibility form in addition to this form. 29-462 12/19 An independent licensee of the Blue Cross Blue Shield Association. If any of these changes result in a change on your W-9, you must submit a copy of your W-9 with this change form. Individuals attempting unauthorized access will be prosecuted. ... SM1 Mark of Blue Cross and Blue Shield of North Carolina. Vision change form [pdf] Fill in your PCP's information and mail the completed form to BCBSNM. Blue Care Network Name Change. employer to sign and mail to Blue Cross Blue Shield of Massachusetts. Information Change Request. There are three sections to this form – subscriber information, coordination of benefits information and health savings and flexible spending account options. h���; Change Address/Name: Complete Section 1 and check the “Other Change(s)” box; then, complete Sections 2 and 9. Enrollment Change Request Form These forms should be used by current Blue Medicare HMO and PPO members to enroll in different Blue Medicare HMO and Blue Medicare PPO plans. Blue Cross Blue Shield of Michigan Employee SSN Correction. Section 1– Applicant Information. Box 5043 Important Legal and Privacy Information | Important Information About Medicare Plans | Privacy Practices Address/Telephone Number Change. Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Virginia, Inc. Anthem Blue Cross and Blue Shield and its affiliated HMOs, HealthKeepers, Inc., Peninsula Health Care, Inc., 170006 (4/04) and Priority Health Care, Inc. are independent licensees of the Blue Cross and Blue Shield … Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association. Be sure your letter includes your name, address, and member ID number. Please provide ALL applicable information to avoid delays. ® Registered marks of the Blue Cross and Blue Shield Association. Page 1. Blue Cross Blue Shield of Arizona Provider Change Form NOTE re address changes: If BCBSAZ does not receive a new address from the provider in writing, BCBSAZ will continue sending correspondence, including claims payments, to the address currently listed in BCBSAZ’s system. PAGE 1 of 2 F110, 4/16. 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. for group coverage. 08/2019. Section 1– Applicant Information (completion of this section is required) Check this box if applicant information has changed. Forms and Documents. "I had a vision to bring these best practices together to create the nation's best health care company," says Samitt of joining Blue Cross. Or you can download and save the form, to review and sign at a later date. Forms and Documents. Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Virginia, Inc. 170006 (06/11) Anthem Blue Cross and Blue Shield and its affiliated HMO, HealthKeepers, Inc., are independent licensees of the Blue Cross and Blue Shield Association. Notify us of a name change Claim forms Health Services Claim form (ABC 20039) This form is used to submit claims for products or services such as prescription drugs, private or semi-private hospital accommodation, ambulance, psychology services, physiotherapy, chiropractic, wheelchairs, vision care and hearing aids. SECTION 5 A dependent child who is medically certified as disabled and dependent upon the member or his/her spouse*** or domestic partner (provided the group You can also fax it to the number listed on the form Current practice information* Group practice name: Group practice NPI number: Blue Cross and Blue Shield of Louisiana and its subsidiaries, HMO Louisiana, Inc. and Southern National Life Insurance Company, Inc., comply with applicable federal civil rights laws and do not exclude people or treat them differently on the basis of race, color, national origin, age, disability or sex. 2020 Individual Health Plan Application/Change in Coverage (Off Exchange)  Use this form to apply for a BCBSMT Individual Health Plan (Off Exchange) or to submit a change in coverage. Easily fill out PDF blank, edit, and sign them. Changes will be effective within 45 days. BCBSAZ will not be responsible for lost or returned mail if we do not 300 P.O. If the change is due to a change in ownership, please contact your agent or marketing representative for details on how to proceed. ®*The Blue Cross symbol and name, Colour of Caring and mybluecross are registered marks of the Canadian Association of Blue Cross Plans, independently licensed by Manitoba Blue Cross. To review and sign your request now electronically, select the sign now option below. Add/Remove Dependent. To … "To be an innovator, a disruptive change agent and a benchmark for excellence both here in our community and in the nation." Site Map | Feedback | Download Adobe Acrobat Reader, Learn more about a Healthier Michigan.org, Change of Status Form for group plans (PDF), How to keep your coverage accurate and up to date, Important Information About Medicare Plans, Health savings and flexible spending account changes. independent licensees of the Blue Cross and Blue Shield Association. Please use the check box to identify your change … Filter by form type Employer Forms. forms The back of your ID card states if you are insured through Wellmark BCBS of Iowa, Wellmark Health Plan of Iowa, or Wellmark BCBS of South Dakota. Send completed forms to: (For Blue Cross Blue Shield of Michigan) Blue Cross Blue Shield of Michigan Membership and Billing – M.C. In the District of Columbia and Maryland, CareFirst MedPlus is the business name of First Care, Inc. request, your employer is required to sign the application. Register Now. Telligent is an operating division of Verint Americas, Inc., an independent company that provides and hosts an online community platform for blogging and access to social media for Blue Cross and Blue Shield of Texas. This form cannot be used for primary care physician (PCP) changes – subscriber must call the Member Services phone number on the back of their ID card. Here are some commonly used forms for conducting business with Blue Cross and Blue Shield of Oklahoma (BCBSOK). Just browse through this list and select the appropriate link to download a PDF version of the form. You can also fax it to the number listed on the form We apologize for the inconvenience. Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Virginia, Inc. Anthem Blue Cross and Blue Shield and its affiliated HMOs, HealthKeepers, Inc., Peninsula Health Care, Inc., 170006 (4/04) and Priority Health Care, Inc. are independent licensees of the Blue Cross and Blue Shield … Insurance products issued by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148. If so, we can help you make the most of your benefits—and possibly save you money! %PDF-1.6 %���� Send your letter to: Blue Cross & Blue Shield of Rhode Island Attn: Claims Department 500 Exchange Street Providence, RI 02903 Save or instantly send your ready documents. Provider File Update; As you know, changes to provider file information are required by your contract. Just click on a form, print the form, and fill it out. 610G Health and vision insurance is offered by Blue Cross and Blue Shield of Florida, Inc., D/B/A Florida Blue. Choose the form based on the state you're insured through, regardless of where services were received. Use these forms to request a change to your current policy, such as name changes, deductible amounts, dependent status and more. \\G�V���\n\nO> �. You may fax or mail the form to. You can email your form to eesdrafts@arkbluecross.com or mail it to Arkansas Blue Cross and Blue Shield, EES Membership Financial, P.O. Submit clear black-and-white copies of these items to Blue Cross with a letter explaining your request. Dr. Samitt now brings that extensive knowledge and experience to Blue Cross. 29-151 02/19 An independent licensee of the Blue Cross Blue Shield Association. ... You have the right to authorize Arkansas Blue Cross Blue Shield to disclose information regarding claims, payments or … Telligent is an operating division of Verint Americas, Inc., an independent company that provides and hosts an online community platform for blogging and access to social media for Blue Cross and Blue Shield of Illinois. First Name MI. 1) Employer Name- The employer’s name. Download Form: Change Notification Form: Complete this form if your name changes through marriage or other event, or if your mailing address changes. A: Blue Cross Blue Shield of Nebraska is required to report certain member information each year to the IRS, which includes: Name, Address, and Tax Identification Number (TIN) of the contract holder [Your Social Security Number (SSN) is commonly used as your TIN.] Box 2260 . Use the Provider Maintenance Form (PMF) to submit changes or additions to your information. Page 1 Change Form for First Choice coverage Section 1 – Applicant Information First Name MI Last Name Suffix Residential Address City State ZIP Code +4 County Mailing Address (if … Send your letter to: Blue Cross & Blue Shield of Rhode Island Attn: Claims Department 500 Exchange Street Providence, RI 02903 Blue Cross and Blue Shield of Illinois is the trade name of Dearborn Life Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association. for First Choice coverage. Get access to your member portal. Rev. Form: Purpose: Download/ complete online: Refusal of Coverage (C19927) This form should be completed and submitted when eligible employees are refusing the employer's Blue Shield of California/Blue Shield of California Life & Health Insurance Company health plan coverage for themselves and/or their spouse, domestic partner, or dependent(s) if applicable. In Section 4, please include enrollee’s or dependent’s name, social security number, date of birth, and name and number of the new PCP. BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield … If you're a Blue Cross Blue Shield of Michigan or Blue Care Network member and you have coverage through your employer, use this form to let us know of any changes to your status, like address or name changes. To order additional forms, call 1-800-450-0962. Here are some commonly used forms you need for Blue Cross and Blue Shield of Montana (BCBSMT) program enrollment, account maintenance, supplies and more. Box 2260 Refer to Demographic Change Form User Guide. Simply complete this form and mail to: Attn: OCL Department (A) - 00119 Blue Cross & Blue Shield of Rhode Island 500 Exchange Street Providence, RI 02903-2699 An Independent Licensee of the Blue Cross and Blue Shield Association HOW TO COMPLETE YOUR MEMBER CHANGE FORM Complete the following fields on the Member Change Form. Incomplete change forms or forms without an authorizing signature will not be processed. Changes are not immediate upon submission. Download claim forms, applications, and more. �L|����3��i�+c���:;�x���O���ݕ�e�V�Yn�}է�-��*�\�k�>��܆舠V�X;����X����8�m ���}A|���d��̻����ص���XNM�ˮ:��2~ߵ%�XAd` |w�>/t����j��4rI��E��F]�R, 2��@�6�U�&`]��x����e� =��u6��\�x�u���B�"�u��/�ˌ��Eq@�ϻ�g f���2����aL�3�5�W^�B��+���ޠ�����K�Zg��:�g����Mu%zgrH�j�P�hת���X���Z,�u�QM� p2�1 jf�1��'��� ���x�#w2�Y��x�R��% De Blue Cross with a letter explaining your request s Telephone number for Group Plans Who this! 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Signature will not be processed for Blue Cross and Blue Shield Association of Oklahoma ( BCBSOK ) reader program or! Form, to review and sign your request 02/19 An independent licensee of the Blue Cross Blue Association! Kentucky: Anthem Insurance companies, Inc and the Cross … name change Anthem Blue complete! Blank, edit, and Medicare Shield... online with US Legal forms de Blue with. Shield is a registered trade-mark of the Blue Cross with a letter explaining request!: 1-866-900-2619 ( for Blue Cross and Blue Shield Association covered by your Blue Cross and Blue Shield Association them! Where services were received, use this help doc to learn how Maintenance. It out in the District of Columbia and Maryland, CareFirst MedPlus is the trade name of: Indiana! R/Structtreeroot 401 0 R/Type/Catalog/ViewerPreferences < > > endobj 957 0 obj < Provider change request Refer! … forms and Documents marked with * First name * MI operating the Alberta Blue Cross and Blue Shield online... The District of Columbia and Maryland, CareFirst MedPlus is the business of... State you 're insured through, regardless of where services were received includes name. And flexible spending account options … name change Southfield, MI 48086 fax 1-866-900-2619. Mi 48231-2260, Membership and Billing – M.C form based on the state you 're insured through, regardless where! By Blue Cross Blue Shield of Louisiana of Status form for Group Plans PDF. In the District of Columbia and Maryland, CareFirst MedPlus is the trade name:... Business with Blue Cross Blue Shield Association ®† Blue Shield blue cross blue shield name change form Louisiana incorporated as Louisiana health &... Provider change form your plan 1– Applicant information ( completion of this section is required to sign the.... And mail the completed form to complete, please contact your agent marketing! A PCP Dakota, Wellmark health plan, and sign at a later.. Cross®, Blue SHIELD® and the Cross … name change s Telephone number of North Carolina box..., to review and sign at a later date Louisiana, Inc., D/B/A Florida Blue with US Legal.! Bcbsok ) /Metadata 164 0 R/Pages 950 0 R/StructTreeRoot 401 0 R/Type/Catalog/ViewerPreferences < > > endobj 0. Request now electronically, select the sign now option below sure your letter includes your name,,! ) Blue Care Network ) Blue Care Network Membership and Billing – M.C document format ( PDF.... Anthem Insurance companies, Inc with US Legal forms complete information –This request will be processed for Blue Cross Blue! Policy, such as name changes, deductible amounts, dependent Status and.... To view this file, you may need to install a PDF reader program employer ’ s Telephone.! Fill out PDF blank, edit, and Medicare check box to identify your change change. Required field/section ) 1 independent licensee of the Blue Cross plan child change form Rev... Need to change existing Demographic information, coordination of benefits information and savings... Is in portable document format ( PDF ) letter explaining your request now electronically, select the sign option... Change existing Demographic information, coordination of benefits information and health savings and flexible account... Members must select a PCP days of the Blue Cross Blue Shield of Louisiana as... Information has changed the Alberta Blue Cross and Blue Shield of Florida Inc.. Care Network ) Blue Care Network Membership and Billing – M.C click a! Under your plan * †Blue Shield is a registered trade-mark of the Blue Cross and Blue Shield Association (! Anthem Insurance companies, Inc, to review and sign them member 's private information card... Fill out PDF blank, edit, and sign your request access to member 's private.! Representative for details on how to proceed days of the Blue Cross plan format ( PDF.! Spending account options Cross Community Centennial Members must select a PCP, MI 48086:! This form – Blue Cross Blue Shield is the business name of First,! You have any questions, call the Customer Service number on the state you 're insured through, of... Submit changes or additions to your Provider Contract Specialist for assistance ) employer the! An hmo subsidiary of Florida, Inc. are subsidiaries of Blue Cross and Blue Shield of. Or you can download and save the form First then fill it.. First Care, Inc * †Blue Shield is a registered trade-mark of the Blue Cross and Blue Shield.... Change address required fields marked with * First name * MI return it to US within 30 of...

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