SINGLE MEDICAL FAMILY MEDICAL
SINGLE DENTAL FAMILY DENTAL
SINGLE COBRA FAMILY COBRA
OTHER___________________________________
CURRENT MAILING ADDRESS
EMPLOYEE AND SPOUSE EMPLOYEE AND CHILDREN EMPLOYEE AND FAMILY
SELECTED PCN
PHYSICIAN*
RELATIONSHIP
TO EMPLOYEE
DEPENDENT
SOCIAL SECURITY NO.
LAST NAME
FIRST NAME
M.I.
SEX
M/F
BIRTH DATE
MO. DAY YR.
HANDI-
CAPPED
**FULL-
TIME
STUDENT
**NAME OF ACCREDITED COLLEGE OR UNIVERSITY ____________________________________________SEMESTER FOR WHICH STUDENT IS ENROLLED_____________________ NUMBER OF HOURS ENROLLED PER SEMESTER__________________
P.O. Box 1460
Little Rock, Arkansas 72203-1460
ENROLLMENT FORM
EMPLOYMENT AND COVERAGE INFORMATION
NAME OF EMPLOYER GROUP # TYPE OF COVERAGE BENEFIT PLAN SELECTED EFFECTIVE DATE
STANDARD PCN/PPO
PCN PPO
Spouse’s Employer: Do you or any member of your family have other health/dental insurance? Yes No Medicare Blue Cross/Blue Shield
Spouse’s Date of Birth: If Medicare, reason for coverage: Over 65 Disabled Kidney Disease Medicare effective date:______________________________
OTHER INSURANCE INFORMATION
IMPORTANT: ALL APPLICATIONS MUST BE SIGNED
COMPLETE FOR FAMILY COVERAGES ONLY:
STREET OR P.O. BOX CITY
STATE
ZIP CODE COUNTY
If yes, please indicate: Policy Holder________________________________________________ Policy #____________________________________________ Type of Coverage: Medical Dental
Insurance Co. Name_____________________________________________________________________________________________ Single Single
Insurance Co. Address___________________________________________________________________________________________ Family Family
BAAA53-01
IS THIS A LATE ENROLLMENT*
EMPLOYEE INFORMATION
SELECTED PCN
PHYSICIAN*
LAST NAME FIRST NAME M.I.
SEX
M/F
BIRTH DATE
MO. DAY YR.
Are you a current, active employee? Ye s No If No, retirement date:__________________________________________________________________________
––
SOCIAL SECURITY NUMBER
DATE OF HIRE
MO. DAY YR.
FOR EMPLOYER USE ONLY
PREEXISTING CONDITIONS
EXCLUSION PERIOD
EXPIRATION DATE
FOR EMPLOYER USE ONLY
PREEXISTING CONDITIONS
EXCLUSION PERIOD
EXPIRATION DATE
YES NO
PLEASE SIGN BELOW:
I hereby authorize any providers of health care services, claim administrators, insurers, reinsurers, and others who have a legitimate need for such information for the purpose of review, investigation, or evaluation of a
claim,
to supply each other with information about my health status and health care services provided to me. I agree that a photographic copy of this authorization is as valid as the original. I also release to BlueAdvantage
Administrators of Arkansas any and all information relative to Title XVIII Medical Claims, or claims with other benefit plans or insurance companies, by or on behalf of me or any covered member of my family, in order to coordinate
benefits with this plan.
If you are enrolling in a PCN program:
I have read and understand the material provided explaining The Primary Care Network and have elected to enroll in this program. I understand that no PCN services (except life threatening or unless otherwise specified by your
plan document) will be covered without being authorized by the Primary Care Physician listed on this application for myself and any eligible family members. I further recognize that I have the right to voluntarily change primary care
physicians participating in The Primary Care Network without losing the additional benefits available under this program. I understand that should I, or a family member covered under my contract, fail to adhere to the provisions
of the Primary Care Network Program, I could be forced to return to the standard benefits program offered through my employer or be forced to encounter additional out-of-pocket expense due to reduced benefit payment.
I further authorize payment direct to my primary care physician, referred physician, hospital or other medical provider for the medical benefits otherwise payable to me.
I understand that all determinations affecting the quality of medical care will be solely between myself and my physicians.
EMPLOYEE SIGNATURE_______________________________________________ EMPLOYER SIGNATURE_______________________________________________ *ENROLLMENT DATE________________________________
I understand that checking this box constitutes a legal signature
