Get Health Plan Employee Enrollment Application Blue Shield Of ...

This guide provides clear and concise instructions for completing the Health Plan Employee Enrollment Application for Blue Shield of California. By following these steps, users can efficiently fill out the application online, ensuring all necessary information is accurately provided.

Follow the steps to complete your enrollment application.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Identify the reason for your application by marking the appropriate checkbox. Options include loss of coverage, open enrollment, new hire, rehire, late enrollment, or other qualifying events.
3. In Section 1, review and understand the enrollment guidelines regarding Specialty Benefits coverage. Note that a dependent can only enroll in dental or vision plans if the employee is enrolled in the same plan.
4. Proceed to Section 2 to select the medical plans you wish to enroll in. Check the boxes for each plan you are interested in, selecting from options available for 51+ employees, both with and without account-based health plans.
5. Complete Section 3 by providing your personal details, such as your social security number, employer name, employment status, job title, and contact information. Indicate your preferred method of communication and date of birth.
6. If enrolling dependents, answer the questions in Section 4. Provide details for each dependent, including their social security number, date of birth, and which plans they are enrolling in.
7. In Section 5, respond to the questions regarding Medicare coverage status. If applicable, attach a copy of your Medicare card.
8. Sign the authorization in Section 6, confirming that all information provided is accurate. It is important to understand that this enrollments needs to be approved for coverage to take effect.
9. After completing the form, you can save any changes. Then, download, print, or share the completed form as needed.

Complete your Health Plan Employee Enrollment Application online today to ensure timely enrollment.