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. Detroit, MI 48231-2260, Membership and Billing – M.C. 2020 Small Group Enrollment Application/Change Form Use this form to … 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. You can also fax it to the number listed on the form 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.] Download Form: Change Notification Form: Complete this form if your name changes through marriage or other event, or if your mailing address changes. Please use the check box to identify your change … C411 h���; In order to complete your enrollment . You might not be able to log in from 2 to 4 a.m. Jan. 9 while we work on the website. You may fax or mail the form to. 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 NPI/Tax ID 3. Provider Change Form (*Denotes a required field/section) 1. Southfield, MI 48086. 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. 01MK5336 R01/18 Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company. ®† Blue Shield is a registered trade-mark of the Blue Cross Blue Shield Association. Section 1– Applicant Information (completion of this section is required) Check this box if applicant information has changed. "To be an innovator, a disruptive change agent and a benchmark for excellence both here in our community and in the nation." Application / Change Form Author: Blue Cross NC 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. HMO Louisiana, Inc. and Southern National Life Insurance Company, Inc. are subsidiaries of Blue Cross and Blue Shield of Louisiana. PAGE 1 of 2 F110, 4/16. Please use the check box to identify your change … Insurance products issued by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148. "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. Thank you for being a part of the Anthem network of health care professionals! First Name MI. 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. Anthem Blue Cross and Blue Shield Agent of Record (AOR) Change Form 49655CEMENABS Rev. Be sure your letter includes your name, address, and member ID number. 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 … 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. Page 1 of 2. To review and sign your request now electronically, select the sign now option below. Current practice information* Group practice name: Group practice NPI number: Unsupported browser. You can email your form to eesdrafts@arkbluecross.com or mail it to Arkansas Blue Cross and Blue Shield, EES Membership Financial, P.O. New Business Enrollment Template with PSA ... Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. 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. Blue Care Network Or you can download and save the form, to review and sign at a later date. Access library of Wellmark forms for BCBS of Iowa, BCBS of South Dakota, Wellmark Health Plan, and Medicare. These are just some of the reasons why it's so important that you notify Blue Cross and Blue Shield of Oklahoma (BCBSOK) when your practice information changes. If so, we can help you make the most of your benefits—and possibly save you money! To view this file, you may need to install a PDF reader program. Employee SSN Correction. 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. ® Registered marks of the Blue Cross and Blue Shield Association. If you do not have Adobe ® Reader ®, download it free of charge at Adobe's site.. Types of Forms Name: Title: Phone: Fax: Email: Date of submission: STANDARDIZED PROVIDER INFORMATION CHANGE FORM (CONTINUED) Provider Name: SUBMISSION INFORMATION: Blue Cross Blue Shield of MA Provider Enrollment Dept. Change Form. 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� �! Change Request Forms - Provider and/or Office File Info Horizon-BCBSNJ-2813-Request-Form-Dental-Change-Provider-File-Info.pdf ... Company d/b/a Braven Health and Horizon Healthcare Services, Inc. d/b/a Horizon BCBSNJ are independent licensees of the Blue Cross and Blue Shield Association. Address/Telephone Number Change. *†Blue Shield is a registered trade-mark of the Blue Cross Blue Shield Association. Send your letter to: Blue Cross & Blue Shield of Rhode Island Attn: Claims Department 500 Exchange Street Providence, RI 02903 Download claim forms, applications, and more. 08/2019. Address/Telephone Number Change. Incomplete change forms or forms without an authorizing signature will not be processed. ... Group Enrollment Application/Change Form – use this form to apply for group coverage or to make changes to an existing BCBSOK policy: ... an Independent Licensee of the Blue Cross and Blue Shield Association. Change Address Required fields marked with * First Name * MI. File is in portable document format (PDF). 29-462 12/19 An independent licensee of the Blue Cross Blue Shield Association. Change Address / Name: In Section 1, check the “Other Change(s)” box, then complete sections 1, 2 and 10. 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. 9/16 Anthem Blue Cross and Blue Shield is the trade name of: In Indiana: Anthem Insurance Companies, Inc. Changes are not immediate upon submission. Easily fill out PDF blank, edit, and sign them. Use these forms to request a change to your current policy, such as name changes, deductible amounts, dependent status and more. Detroit, MI 48226 . 954 0 obj <> endobj 1057 0 obj <>/Encrypt 955 0 R/Filter/FlateDecode/ID[<04FB223B94464F3DAEC32D19504ECC94><174DF615DCD44E4F9217370370D51CDD>]/Index[954 297]/Info 953 0 R/Length 218/Prev 165940/Root 956 0 R/Size 1251/Type/XRef/W[1 3 1]>>stream BCBSAZ will not be responsible for lost or returned mail if we do not Forms and Documents. Changes will be effective within 45 days. The Blue Cross and Blue Shield Association does not have access to member information. On the top of the form, let us know which plan you are enrolled in by checking the box for either Blue Cross Blue Shield of Michigan or Blue Care Network member. Please email the completed form to: small.group.sales.support@bluecrossmn.com, or Mail to: Small Group Sales Support N187 Blue Cross and Blue Shield of Minnesota PO Box 64560 St. Paul, MN 55164-0560. Forms and Documents. Box 5043 A subsidiary of Blue Cross and Blue Shield of Louisiana, q EMPLOYEE ENROLLMENT q EMPLOYEE CHANGE FORM independent licensees of the Blue Cross and Blue Shield Association. If so, we can help you make the most of your benefits—and possibly save you money! Legal Name; NPI/Tax ID In-network Providers or Groups – Prior to changing a TAX ID or requesting termination from a provider network, ... a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association. In Section 1, check the “Other Change(s)” box, then complete sections 2, 3, 4 and 10. Address change: Instructions for Completing Blue Cross Blue Shield of Michigan Individual Coverage Change of Status This form is intended for use by current Blue Cross members to report changes to their contract during a qualifying life event. �%RC� ��y�W,��ӲMR���@[��^3�s����v��i���>���[�g1� t��E��X'\�m�}�tm�������e��,����V���[2�[yx�F����&q�|����9��n���V���,L�&QR���s�]MW�����s{��X%��c�y+�lk �)=|�L��ύF����Yߐ%�i@���4�_��ϛO!V@�������c]���%��i+�N�yA�6� Complete GROUP ENROLLMENT/CHANGE FORM - Blue Cross Blue Shield online with US Legal Forms. Name Change. Or you can download and save the form, to review and sign at a later date. 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. Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association ... the date the Plan receives your request for the change. State and Federal Privacy laws prohibit unauthorized access to Member's private information. P.O. ... An independent licensee of the Blue Cross and Blue Shield Association. 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. Register Now. These forms are available as PDF files. It is not an application for coverage. ®*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. PO Box 55350 Boston, MA 02205-5350 Email: provider-enrollment@bcbsma.com Fax: (617) 246-7771 Phone: (800) 316-BLUE (2583) for First Choice coverage. Office Physical Address/Telephone/Fax/Email/Hours of Operation (Note: When submitting changes, please indicate in t… If you buy your own coverage and you need to make changes to your information, use this help doc to learn how. 610I P.O. ... An independent licensee of the Blue Cross and Blue Shield Association. Get access to your member portal. Home Office 4000 House Ave. First Care, Inc., and The Dental Network, Inc. are independent licensees of the Blue Cross and Blue Shield Association. Box 2260 . BLUE CROSS®, BLUE SHIELD® and the Cross … PROVIDE COMPLETE INFORMATION –This request will be processed for Blue Cross Complete of Michigan. �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��% We regulate the brand and licenses to all 36 Blue Cross and Blue Shield local companies. ... SM1 Mark of Blue Cross and Blue Shield of North Carolina. Dr. Samitt now brings that extensive knowledge and experience to Blue Cross. Just click on a form, print the form, and fill it out. 2) Telephone Number- The employer’s telephone number. Provider File Update; As you know, changes to provider file information are required by your contract. 2020 Individual Dental Application/Change in Coverage Use this form to apply for a BlueCare Dental Individual Plan effective January 1, 2020, or to make changes to an existing BCBSMT policy. 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 … Special Instructions for Student Coverage: If you’re seeking coverage for a full-time student dependent over age 19, you may need to fill out a Student Certificate form. Send your letter to: Blue Cross & Blue Shield of Rhode Island Attn: Claims Department 500 Exchange Street Providence, RI 02903 Box 2260 First Name MI. Box 5043 Southfield, MI 48086 Fax: 1-877-218-1466 ��KɆj��R{�M�cQ��N0�XP۶��ܰ�5 bR)A]Us��� ���z�������� ��JQv ��VFS"�؎��lQ�*�)�O�F�͞|�2��b���D���}�2�%s��c� �B�پ�4|���`W���C&�|/V�7�+�[])?t�JR�"|���E��)��aqmčO��0O��#5?g��3��G>*T2���A�fO�p�W��x`�j� 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. You can also fax it to the number listed on the form ... SM1 Mark of Blue Cross and Blue Shield of North Carolina. 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. Here's the form: Change of Status Form for group plans (PDF). Be sure your letter includes your name, address, and member ID number. To order additional forms, call 1-800-450-0962. 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. 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. In Kentucky: Anthem Health Plans of Kentucky, Inc. 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 Filter by form type Employer Forms. Box 34320, Little Rock, AR 72203-4320. Change Form. independent licensees of the Blue Cross and Blue Shield Association. 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. In the District of Columbia and Maryland, CareFirst MedPlus is the business name of First Care, Inc. X�6y�d҇��X�ʩ�cb�TW���e�����Q'y�J':�/N�7?�+��H(۞z^��:��;s֛��1ۘ����;[?���! for group coverage. Change Address/Name: Complete Section 1 and check the “Other Change(s)” box; then, complete Sections 2 and 9. PROVIDER CHANGE REQUEST FORM PROVIDE COMPLETE INFORMATION –This request will be processed for Blue Cross Complete of Michigan. 29-151 02/19 An independent licensee of the Blue Cross Blue Shield Association. 1) Employer Name- The employer’s name. SECTION 5 Primary Care Provider Selection Form – Blue Cross Community Centennial Members must select a PCP. Health and vision insurance is offered by Blue Cross and Blue Shield of Florida, Inc., D/B/A Florida Blue. 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. �@��u���H�h��x�x�B��A����J�m�3Ic3�!��Xn�1�;3ˮVDm�D΁UGxc�� 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. P.O. request, your employer is required to sign the application. Third Party Website Icon: Please be aware when you are on the Blue Cross and Blue Shield of Minnesota (Blue Cross) website and see this Third Party Website icon, you will be connected to a third party site, whether via links provided by Blue Cross or otherwise, and you will be subject to the privacy policies of the third party sites. 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 … We apologize for the inconvenience. Save or instantly send your ready documents. Home Office 4000 House Ave. 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. Change Form. Independent licensee of the Blue Cross and Blue Shield Association. Last Name Suffix Residential Address City. Blue Cross Blue Shield of Michigan Download Form: Change Notification Form: Complete this form if your name changes through marriage or other event, or if your mailing address changes. 29-462 12/19 An independent licensee of the Blue Cross Blue Shield Association. Rev. File is in portable document format (PDF). Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association. If you are unsure which form to complete, please reach out to your Provider Contract Specialist for assistance. 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 34320, Little Rock, AR 72203-4320. Change of Status Form for Group Plans Who is this for? You may choose to make changes to the online form, then print; or print the form first then fill it out. If you have any questions, call the Customer Service number on the back of your ID card or contact your employer. 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. If the change is due to a change in ownership, please contact your agent or marketing representative for details on how to proceed. 610G Name and TIN of each dependent who is covered under your plan. Requests … PAGE 1 of 2 F110, 4/16. \\G�V���\n\nO> �. Section 1– Applicant Information. Not Registered? ® Registered marks of the Blue Cross and Blue Shield Association. There are three sections to this form – subscriber information, coordination of benefits information and health savings and flexible spending account options. 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 Do you or anyone else covered by your Blue Cross health plan have another health plan? employer to sign and mail to Blue Cross Blue Shield of Massachusetts. [u�&l�1���K�rQ{ifz]�Vd6x)����[��/�D��C� .5G endstream endobj startxref 0 %%EOF 1250 0 obj <>stream 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. Last Name Suffix Residential Address City. Just browse through this list and select the appropriate link to download a PDF version of the form. You can email your form to eesdrafts@arkbluecross.com or mail it to Arkansas Blue Cross and Blue Shield, EES Membership Financial, P.O. Change Request Forms - Provider and/or Office File Info Horizon-BCBSNJ-2813-Request-Form-Dental-Change-Provider-File-Info.pdf ... Company d/b/a Braven Health and Horizon Healthcare Services, Inc. d/b/a Horizon BCBSNJ are independent licensees of the Blue Cross and Blue Shield Association. Important Legal and Privacy Information | Important Information About Medicare Plans | Privacy Practices )/MarkInfo<>/Metadata 164 0 R/Pages 950 0 R/StructTreeRoot 401 0 R/Type/Catalog/ViewerPreferences<>>> endobj 957 0 obj <. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan. Do you or anyone else covered by your Blue Cross health plan have another health plan? Newborn and adopted child change form [pdf] 2. Change forms. Choose the form based on the state you're insured through, regardless of where services were received. 1. Vision change form [pdf] 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. Complete Enrollment Application/Change Form - Blue Cross And Blue Shield ... online with US Legal Forms. Membership and Billing – M.C. Change Form. ... Blue Cross and Blue Shield of North Carolina es un concesionario independiente de Blue Cross and Blue Shield Association. On the top of the form, let us know which plan you are enrolled in by checking the box for either Blue Cross Blue Shield of Michigan or Blue Care Network member. Name Change. 300 P.O. Easily fill out PDF blank, edit, and sign them. Please provide ALL applicable information to avoid delays. Use the Provider Maintenance Form (PMF) to submit changes or additions to your information. Employee SSN Correction. When seeking health care services, our members often rely upon the information in our online Provider Finder ®.This is just one of the reasons why it’s very important that you inform Blue Cross and Blue Shield of New Mexico (BCBSNM) whenever any of … ©1996-document.write(new Date().getFullYear()); Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Submit clear black-and-white copies of these items to Blue Cross with a letter explaining your request. There are three sections to this form – subscriber information, coordination of benefits information and health savings and flexible spending account options. 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. %PDF-1.6 %���� Here are some commonly used forms you need for Blue Cross and Blue Shield of Montana (BCBSMT) program enrollment, account maintenance, supplies and more. We provide health insurance in Michigan. 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. 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 … Changes will be effective within 45 days. Individuals attempting unauthorized access will be prosecuted. Fill in your PCP's information and mail the completed form to BCBSNM. 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. To … Here are some commonly used forms for conducting business with Blue Cross and Blue Shield of Oklahoma (BCBSOK). If you need to change existing demographic information, complete the Demographic Change Form . 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. Submit clear black-and-white copies of these items to Blue Cross with a letter explaining your request. Refer to Demographic Change Form User Guide. Complete the form and return it to us within 30 days of the change. BCBSAZ will not be responsible for lost or returned mail if we do not We apologize for the inconvenience. Independent licensee of the Blue Cross and Blue Shield Association. 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. Information Change Request. 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. To review and sign your request now electronically, select the sign now option below. Save or instantly send your ready documents. HMO coverage is offered by Health Options, Inc., D/B/A Florida Blue HMO, an HMO subsidiary of Florida Blue. (Please check the appropriate boxes and complete only those Health Service & Indemnity Company identify your change … forms and Documents sections to this –. 01Mk5336 R01/18 Blue Cross and Blue Shield... online with US Legal forms are subsidiaries Blue! Online with US Legal forms, BCBS of Iowa, BCBS of Iowa, of! 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