Get Enrollment/change Request Form - Horizon Blue Cross Blue Shield ...

This guide provides comprehensive instructions for completing the Enrollment/Change Request Form for Horizon Blue Cross Blue Shield online. It is designed to support individuals and employers in navigating the form effectively and accurately.

Follow the steps to complete your Enrollment/Change Request Form online.

1. Use the ‘Get Form’ button to access the Enrollment/Change Request Form. This will allow you to download or open the form for editing.
2. Begin by filling out the 'Group Information' section, which should be completed by the employer. Include the group name, group number, sub-group number, hire date, effective date, and the reason for the request.
3. Proceed to 'Type of Activity' and select the appropriate option: Add, Remove, or Other Change. Ensure that you understand the instructions provided before making your selection.
4. In the 'Employee Information' section, provide details such as the employee's full name, social security number, date of birth, sex, and home address. Indicate if the request is for adding, removing, or continuing coverage.
5. Complete the ‘Coverage Continuation’ section if applicable, providing details on any additional health coverage and the primary care provider.
6. In the 'Race/Ethnicity' section, complete this optional field according to your preference. Choose an appropriate category if you wish to disclose your information.
7. Move on to the 'Plan Options' section where the employee must select from the available medical, dental, and vision coverage options as provided by the employer.
8. Fill in the 'Other Individuals Covered' section, including information about any dependents if applicable. You may need to attach additional pages for more listings.
9. Complete the 'Employee Signature' section. This confirms that the information provided is accurate. Remember to date your signature.
10. If applicable, have any over-age children sign where indicated, acknowledging the continuation of their coverage.
11. Finally, ensure all necessary fields are filled out, review your entries for accuracy, and save your changes. You can print, download, or share the completed form as necessary.

Ready to complete your Enrollment/Change Request Form online? Follow the steps outlined in this guide to get started.