Anthem Blue Cross Application Form – Fill Out and Use This PDF

Individual Application

Indicate subscriber’s ID Number for existing Anthem Blue Cross plan and/or Anthem Blue Cross Life and Health Insurance Company policy: ____________________________

NOTE: If you are adding a dependent or changing benefit options the effective date will always be the first of the month following approval.

Effective date requested: If your application is approved, Anthem will assign an effective date of coverage. The effective date assigned by Anthem may not be the same date as your requested effective date and requesting an effective date is not a guarantee that coverage will be effective on such date.

Please choose the date you would like your coverage to start: ______/______/___________ MM/DD/YYYY

IMPORTANT: PREMIUM PAYMENT IS REQUIRED TO BE SUBMITTED WITH YOUR APPLICATION.

Please complete the Payment Method for Individual Applications Form and send it with your completed enrollment application. Applications received with no premium payment will be returned which may impact your eligibility for coverage. If you have any questions, please call 1-800-333-0912.

1. Primary Applicant Information (Please print)

oApplicant DOES speak, read and/or write English. If applicant does not speak, read or write English, the interpreter must sign and submit a Statement of Accountability (Section 8).

Please provide your communication method of choice for all underwriting correspondence during the review of your application: o E-mail oFax o Mail

*Anthem is required by the IRS to collect this information. It is used for internal purposes only and will not be disclosed unless you select the health savings account option in this Application or to federal and state agencies as required by applicable law.

**All information will be mailed to your home address, including billing, private and confidential communications as defined by California law, unless you designate a different address under the "Mailing Address" field above. This will not impact rights you may have to invoke a separate Confidential Communication under the Health Insurance and Portability and Accountability Act ("HIPAA").

2. Choice of Anthem Blue Cross Plan and/or Anthem Blue Cross Life and Health Insurance Company Policy

Family members 19 years of age and older may select a different medical plan/policy by using the FamilyElectSM option. To do so, refer to the 4-digit codes in parentheses below and indicate your medical benefit options in Section 3B for each family member.

If you want one medical plan/policy for all family members, please select a box below. Anthem Blue Cross and/or Anthem Blue Cross Life and Health Insurance Company will enroll all eligible family members unless otherwise instructed.

oI, the Applicant, request that Anthem Blue Cross and/or Anthem Blue Cross Life and Health Insurance Company not enroll any eligible applicants unless ALL family members qualify. If you are choosing Dental coverage, please complete the appropriate sections that follow.

Agent Name/TIN

Medical Benefit Options

If you have chosen a Health Savings Account (HSA) product, choose the following:

o Yes, I would like to establish an HSA. Please forward my information to Anthem Blue Cross’ banking partner.

o No, I DO NOT want to establish an HSA. Please DO NOT forward my information to Anthem Blue Cross’ banking partner.

HMO Plans

Dental Select HMO plans are offered by Anthem Blue Cross. Dental Blue plans are offered by Anthem Blue Cross Life and Health Insurance Company.

*These products are administered by Anthem Blue Cross and are regulated by the California Department of Managed Health Care. All other products are administered by Anthem Blue Cross Life and Health Insurance Company and are regulated by the California Department of Insurance.

†If you are enrolling in any of the Anthem Blue Cross Dental SelectHMO plans, please enter the number of the Dental Office you have chosen in the space above. If I purchase optional dental benefits, I understand that I may have a waiting period for the coverage.

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For Tonik and Lumenos Plus HSA Individual policies, each member will be enrolled on his/her own policy. All approved applicants will be assigned the same effective date of coverage as long as there is no break in coverage for any applicant.

o Please check box if any additional sheets of paper have been completed for this section. If so, please attach and return the additional sheets with this application.

My domestic partner, if applicable, is eligible for coverage only if he or she has established a domestic partnership with me pursuant to California law.

If a family member’s last name is different from the primary applicant‘s last name, please explain: _________________________________________________________________

_________________________________________________________________________________________________________________________________________

*Anthem is required by the IRS to collect this information. It is used for internal purposes only and will not be disclosed unless you select the health savings account option in this Application or to federal and state agencies as required by applicable law.

**If an applicant under 19 qualifies as a Late Enrollee, please attach a copy of the completed Late Enrollee Questionnaire.

***PMG = Participating Medical Group, IPA = Independent Practice Association

INSTRUCTIONS:

Primary Applicant - please complete and return Section 5, Health History page 7a (Primary Applicant) through page 10a (Primary Applicant).

Spouse/Domestic Partner - please complete and return Section 5, Health History page 7b (Spouse/Domestic Partner) through page 10b (Spouse/Domestic Partner). Dependent 1 - please complete and return Section 5, Health History page 7c (Dependent 1) through page 10c (Dependent 1).

Dependent 2 - please complete and return Section 5, Health History page 7d (Dependent 2) through page 10d (Dependent 2).

If there are no Spouse/Domestic Partner, Dependent 1, or Dependent 2 applicants, you do not need to return Section 5, Health History pages indicated for those applicants.

If there are additional Dependent applicants (Dependent 3 or Dependent 4), please complete copies of Section 5, Health History, write by the page number if it is Dependent 3 or Dependent 4 and return with the other completed sections of the application.

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4. Prior Insurance History

Please answer ALL of the following questions.

Anthem Blue Cross and/or Anthem Blue Cross Life and Health Insurance Company credits prior coverage toward the pre-existing period for those applicants who apply for coverage within 63 days after termination of qualifying prior coverage. To obtain credit toward the pre-existing waiting period, please complete the following questions. Pre-existing condition limitations do not apply to applicants under the age of nineteen (19) unless you are adding an applicant under the age of 19 to your coverage which was effective prior to March 23, 2010.

Pre-existing Conditions: For applicants age nineteen (19) and older, no payment will be made for services or supplies for the treatment of a pre-existing condition during a period of six (6) months following your Effective Date. However, we may apply Creditable Coverage to satisfy or partially satisfy the six (6) month period if you become eligible for coverage within 62 days of termination of your qualifying prior coverage (exclusive of any waiting or affiliation period), and you apply with Anthem Blue Cross and/or Anthem Blue Cross Life and Health Insurance Company no longer than 63 days after termination of your qualifying prior coverage. HMO medical plans do not have a pre-existing waiting period.

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