Get C12900 Rd Form

The C12900 Rd Form is essential for applying to Blue Shield of California's individual and family health plans. This guide provides clear and supportive instructions for filling out the form online, ensuring you navigate the process easily and accurately.

Follow the steps to complete the C12900 Rd Form online.

1. Click the ‘Get Form’ button to obtain the C12900 Rd Form and open it in your online editor.
2. Fill out Part 1, which includes primary applicant information. Ensure to provide your full name, social security number, date of birth, gender, and contact information.
3. Indicate the reason for application and select if you’re enrolling or transferring plans.
4. Complete the supplemental plan choices in Part 2, selecting any additional coverage options such as dental or life insurance.
5. In Parts 3(a) and 3(b), provide details about dependents applying alongside you, including their names, dates of birth, and health plan options.
6. Fill out Part 4 concerning prior medical coverage, carefully answering if you or your dependents had other coverage within the specified time frames.
7. Complete Part 5, the health questionnaire, by answering each question truthfully for all applicants. Mark 'Yes' or 'No' as applicable.
8. Review the authorization for the release of information in Part 6 and complete your signature to validate the application.
9. In Part 7, provide your verification of accuracy and make sure each applicant over the age of 18 signs the application.
10. Follow the instructions in Part 10 to calculate and include the first month's premium before submitting your application.
11. Save your changes, download the completed form, print it, or share it as required. If necessary, reach out to Blue Shield or your agent for assistance.

Start filling out the C12900 Rd Form online today to secure your health coverage!