HSA HSA Opt out BCBSM FSAMED FSADEPCA
Benefit code: Plan code:
Person covered (full name)
Policy number CarrierEmployer or group name
M F
BCBSM group number
Subscriber information
- -
Subscriber first name
S
M
Primary phone
- -
Home street address
City State
Secondary phone
- -
ZIP Code
County
E-mail - optional
SUBSCRIBER NEW ENROLLMENT
List all persons to covered:
Last name First name
MI
Date of birth
/ /
/ /
/ /
/ /
Social Security number
Spouse
Dep. 1
Dep. 2
Dep. 3
If the permanent address of the spouse or dependent is different from the address above, please complete the information below:
Spouse or dependent (full name) Street address City
State ZIP code
Do you, your spouse or dependent(s) maintain other health coverage?
Yes No
If Yes, complete below:
Address
Are any members listed enrolled in Medicare?
No Yes
If Yes, check reason category
Working Aged Retired Disabled ESRD
Subscriber
signature:
Country - if other than USA
M.I.
*Relationship
code (see
instructions
for codes)
Division
-
M
F
BCN group ID Subgroup ID
Subscriber birth date
/ /
Page 2 of 7 CF 3599 APR 12
Class ID
Check here if this applies to all members on the contract:
Marital Status
Gender
BCBSM BCN Member
- Complete Page 4 for PCP Selection
Employer representative signature
Date
/ /
Social Security number (Required)
Home
Work
Cell
Home
Work
Cell
Dep. 4
/ /
Coordination of benefits information
I have read and understand
the conditions of this form.
Date:
/ /
Health savings and flexible spending account options
Employer/Group use only
New
Rehire
Full time
Part time
Transfer
Return from layoff
Retiree
Hourly
Salary
Surviving spouse
Open enrollment
Loss of eligibility
Check
type of
enrollment
:
Termination
Reduction of hours
Deceased subscriber
Divorce or legal separation
Loss of dependent status
Layoff
COBRA enrollment
Check reason:
Average hours worked
per week (required):
Job title (required):
Gender
Group
Employee
Effective
/ /
M F
M F
M F
M F
Medical Dental Vision
Check coverage if applicable :
Loss of eligibility (prior coverage) Yes No
If Yes, complete below:
Carrier's name (Including BCBSM and BCN): Contract holder name Policy#
Termination date:
/ /
Subscriber last name
Original qualifying date
/ /
Previous contract #
Medicare A effective date
/ /
Medicare B effective date
/ /
Medicare Part D effective date
/ /
Medicare primary
BCBSM or BCN primary
HIC#:
Date of hire:
/ /
ID badge #:
name:
date:
Goal amount: Goal amount:
(see Page 3 for instructions)
(prior coverge)
Product indicator code:
1385617854