Get Enrollment Change Of Status Form (ecos) - Employee Benefits ...

The Enrollment Change Of Status Form (ECOS) is a crucial document for managing employee benefits and ensuring accurate coverage for you and your family members. This guide provides clear step-by-step instructions to help you fill out the form accurately and efficiently online.

Follow the steps to fill out the Enrollment Change Of Status Form (ECOS) effectively.

1. Click ‘Get Form’ button to access the Enrollment Change Of Status Form and open it in your browser for online editing.
2. Begin by entering the subscriber's Social Security Number or assigned contract number. Include the relevant BCBSM Group and Suffix number or BCN Group ID.
3. Fill in the Subscriber Last Name, First Name, and Middle Initial. If there isn't enough space to write your full name, use the remarks section at the bottom of the form.
4. Indicate your marital status and gender, and enter your date of birth along with your home and work phone numbers.
5. Provide your home address details including street address, city, state, and zip code. Specify the county name and your email address, if desired.
6. List all individuals to be enrolled or terminated, including their names, gender, date of birth, and Social Security numbers. Specify whether you are adding or deleting each person.
7. For BCN/POS users, list the Primary Care Physician’s last name, first initial, physician number, and location, and indicate if each member has seen the PCP in the past 12 months.
8. Indicate if you, your spouse, or any dependents have other health coverage and provide the necessary details if applicable.
9. Check the appropriate status for Medicare enrollment and attach a copy of the Medicare card(s) if necessary.
10. In the signature section, provide your full name and the date you completed the form. Make any remarks in the designated area.
11. Once all sections are completed, review for accuracy, and save your changes. You can choose to download, print, or share the completed form as needed.

Complete your Enrollment Change Of Status Form online today to ensure your benefits are accurately managed.