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Get Excellus B-274 2003-2025
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How to fill out the Excellus B-274 online
Filling out the Excellus B-274 form online is an essential step for individuals electing to enroll in the Employer Group Plan as primary coverage for those over 65. This guide provides clear, step-by-step instructions to help users complete the form accurately and efficiently.
Follow the steps to complete the Excellus B-274 form online.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- In the 'Group Name' field, enter the name of the employer group associated with the plan.
- Fill out the 'Date' field with the current date when you are completing the form.
- In the 'Group Number' field, provide the unique identification number for the employer group.
- Enter the 'Group Telephone Number' for any associated inquiries.
- Have the 'Group Representative' sign the form and include the date of their signature.
- For the section pertaining to the over 65 active employee or spouse, locate the 'Subscriber #' field and input the corresponding subscriber number.
- Fill in the 'Employee Name' using the full name of the active employee.
- In the 'Medicare Health Insurance Claim ID #' field, input the claim ID in the format provided.
- Complete the effective dates for Medicare Part A and Part B as applicable for the employee.
- If not eligible for Medicare Part A or B, provide required reasons in the designated fields.
- Repeat steps 7 to 11 for the spouse’s information, if applicable.
- Once all fields are filled out completely and accurately, review the information you provided.
- Save changes, download the completed form, print it, or share it as required.
Complete your documents online today to ensure you have the necessary coverage.
In New York, BlueCross BlueShield is known as Excellus BlueCross BlueShield. This brand ensures that residents have access to a range of health insurance options. The Excellus B-274 plan is one example of how they cater to diverse healthcare needs, making it important for New Yorkers to know this distinction.
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