Get Pa Independence Blue Cross Away From Home Care Guest Membership Application 2019-2025

This guide provides step-by-step instructions to assist you in filling out the PA Independence Blue Cross Away From Home Care Guest Membership Application online. By following these instructions, you can ensure a smooth application process.

Follow the steps to complete your application effectively.

1. Select the ‘Get Form’ button to access the application form and open it in your preferred editor.
2. Begin by entering today's date in the designated field at the top of the form. This helps establish the timeline for your membership application.
3. Fill out the subscriber information section. Include the subscriber's name, employer, address, city, state, zip code, suite/apartment number, member ID number, and both home and alternative phone numbers.
4. Proceed to the guest member information section. Input the guest member's name, away from home address (ensuring it is USPS verified), social security number, city, state, zip code, county, and phone number.
5. If there are other members applying for guest membership, provide their names, social security numbers, genders, and away-from-home addresses in the space provided.
6. Complete the guardian information section. This is necessary if the guest member is under the age of 18. Include the guardian's name and relationship to the guest member.
7. Fill out the guest membership details by selecting the type of guest membership you are seeking. Make sure to note the reasons for applying and provide any specific dates related to the guest member's return home.
8. Ensure to complete and attach the other insurance questionnaire found on pages 4 and 5 of the application. This is important for processing your request without delays.
9. Review all entered information for accuracy and completeness. Check that the subscriber's signature is included along with the date.
10. Once all sections are complete, save your changes, then either download, print, or share the completed application as required.

Take the next step towards obtaining your guest membership by completing the application online.