Xviepo Form – Fill Out and Use This PDF

Anthem Blue Cross Enrollment Form

Please return the completed enrollment form to your employer.

Effective date (MM/DD/YY)

Group no.

Purpose:

New enrollment

Re-hire

Part-time to full-time

Open enrollment

Family addition

Change

COBRA

Cal-COBRA

Section 1: Type of coverage — Select from only the coverages offered by your employer.

Medical

Anthem Blue Cross plans:		Anthem Blue Cross Life and Health Insurance Company plans:
HMO1	Select HMO1		PPO (Prudent Buyer)		CareAdvocate PPO	Consumer Driven Health Plans:
Preferred HMO 1	Vivity HMO1		EPO (Prudent Buyer Exclusive)		Select PPO	(select one of the following)
Advantage HMO1	Clear Value		POS (Blue Cross Plus)1		BC PPO (non-California resident)	H.S.A.2	H.R.A.
Priority Select HMO1	Elements Choice (EQ) HMO1		Elements Choice (EQ) PPO		BC Exclusive (non-California resident)	H.I.A. Plus
			Medicare		BC CareAdvocate PPO	Elements Choice (EQ) HSA
Other: ___________________________________________________						(non-California resident)
1 Indicate Medical Group/IPA No. in the Employee and family informationsection.
2 Anthem will facilitate the opening of a Health Savings Account in your name, if directed by your employer.
Dental
Anthem Blue Cross plans:	Anthem Blue Cross Life and Health Insurance Company plans:
Dental Net HMO3		Dental Consumer Choice		Dental Consumer Choice Voluntary		Dental Blue PPO
Choice Dental		Dental Essential Choice		Dental Essential Choice Voluntary		PPO Dental
(select one of the following)		Dental Prime		Voluntary PPO Dental		National Dental Blue PPO
Dental Net HMO3		Dental Complete		Dental Blue Complete Incentive		National PPO Dental
PPO Dental		Dental Prime Voluntary				National Voluntary PPO Dental
		Dental Complete Voluntary

Other: ___________________________________________________

3 Indicate Dental Office No. in Employee and family informationsection 3.

UNIACCOUNT (Flexible Spending account)4	(Indicate payroll deductions)
I authorize payroll deductions as follows:	Health Care Account $_________	Dependent Care $_________

4 Anthem PPO, drug and dental plan enrollees, will have out-of-pocket expenses, automatically deducted from their Health Care FSA account. Automatic FSA processing is not possible for HMO enrollees and those with coverage through another health plan. Reminder: Automatic FSA processing is the equivalent of signing and submitting an FSA claim form, which states that you are eligible for FSA reimbursement and that you will not claim FSA reimbursed expenses on your income tax return.

Vision	Blue View Vision (offered by Anthem Blue Cross Life and Health Insurance Company)
Life insurance	All the coverages listed may not be offered by your employer. To elect dependent coverage, the corresponding employee coverage	Annual salary
	must be selected. List all life insurance beneficiaries in the Life insurance beneficiary designation informationsection.	$

Language choice (optional)

English

Spanish

Chinese

Korean

Other — please specify: _________________________________

Section 2: Applicant’s personal information

Social Security no. required under CMS Regulations and by the IRS.

Last name

First name

M.I.

Marital status

Social Security or ID no.5 (required)

Single

Married

Domestic Partner (DP)

Mailing address

Apt. no.

No. of dependents including

Spouse/DP Social Security or ID no.5

spouse

(required)

City

State

ZIP code

Home phone no.

Hire date/Rehire date

Employer name

Job title

Class

Dept. no.

Email address

Part-time to Full-time date

(MM/DD/YY)

TobeeligibleasaDomesticPartner,theSubscriberandDomesticPartnermusthaveproperlyfiledaDeclarationofDomesticPartnershipwiththeCaliforniaSecretaryofStatepursuant totheCaliforniaFamilyCode,orhaveproperlyfiledanequivalentdocumentinaccordancewiththelawsofanotherjurisdictionrecognizingthecreationofdomesticpartnerships.

5AnthemisrequiredbytheInternalRevenueServicetocollectthisinformation.

Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. The Blue Cross name and symbol are registered marks of the Blue Cross Association. Medical and Dental coverage provided by Anthem Blue Cross and/or Anthem Blue Cross Life and Health Insurance Company. Vision, Life and Disability insurance plans offered by Anthem Blue Cross Life and Health Insurance Company. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc.

	anthem.com/ca	1
	GC4050 Rev. 5/17 (effective date 10/17)

Social Security or ID no.1 (required)

Section 3: Employee and family information — Please list yourself and all eligible family members to be enrolled. Attach additional sheets if necessary.

					Social Security		If children are	HMO & POS ONLY		Dental Net
				Birthdate	or ID no.1	Full-time		IPA/Primary Care	Current	ONLY
Sex	Last Name	First Name	M.I.	(MM/DD/YY)	(required)		age 26 or over	Physician code	MD?	Office no.
						student	you must check
	Employee
M						(if	the appropriate		Yes
						applicable,
F							boxes below		No
						for
M	Spouse/DP								Yes
						non-medical	IRS Qualified
F						plans)	Dependent		No
M						Yes	Yes		Yes
F						No	No		No
M						Yes	Yes		Yes
F						No	No		No
M						Yes	Yes		Yes
F						No	No		No
M						Yes	Yes		Yes
F						No	No		No

Section 4: Declination — Please complete if any coverage is declined or refused by an eligible employee and/or their eligible dependents.

I acknowledge that the available coverages have been explained to me by my employer and I know that I have every right to apply for coverage. I have been given the chance to apply for this coverage and I have decided not to enroll myself and/or my dependent(s), if any. I have made this decision voluntarily, and no one has tried to influence me or put any pressure on me to decline coverage. BY DECLINING THIS GROUP MEDICAL COVERAGE (UNLESS EMPLOYEE AND/OR DEPENDENTS

HAVE GROUP MEDICAL COVERAGE ELSEWHERE) I ACKNOWLEDGE THAT MY DEPENDENTS AND I MAY HAVE TO WAIT UNTIL THE NEXT OPEN ENROLLMENT PERIOD TO BE ENROLLED IN THIS GROUP MEDICAL AND/OR GROUP LIFE INSURANCE PLAN.

Section 5: COBRA/Cal-COBRA coverage information — Complete only if enrolling in COBRA/Cal–COBRA.

Reason for COBRA/Cal-COBRA coverage

Federal COBRA qualifying event date	Federal COBRA coverage begin date	Federal COBRA coverage end date
Cal-COBRA qualifying event date	Cal-COBRA coverage begin date	Cal-COBRA coverage end date

1AnthemisrequiredbytheInternalRevenueServicetocollectthisinformation.

GC4050 Rev. 5/17 (effective date 10/17)

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Social Security or ID no.1 (required)

Section 6: Other coverage for all enrolling employees and dependents — All questions must be answered.

A. Do any persons on this application intend to continue other group coverage if this application is accepted?

Yes

No

If yes, name of person(s): ______________________________________________________________________________________

Insurance company: ___________________________________ Policy no. ____________________ Phoneno. __________________

B. Does any person applying for coverage currently have health insurance coverage?	Yes	No
Has any person applying for coverage had health insurance coverage at any time in the past six months?	Yes	No

If yes, applicant/family member name(s): ____________________________________________________________________________

Type of continuous coverage: Group

Individual

Other: __________________________________________________________

Insurance company: ___________________________________

Policy no. ____________________ Phoneno. __________________

Date coverage began:

Date ended:

(MM/DD/YY)

C. Does any person applying for coverage currently have dental insurance coverage?

Yes

No

If yes, applicant/family member name(s): ____________________________________________________________________________

Type of continuous coverage: Group

Individual

Other: ________________________________ Includes orthodontia? Yes

No

Insurance company: ___________________________________

Policy no. ____________________ Phoneno. __________________

Date coverage began:

Date ended:

(MM/DD/YY)

D. Does any person applying for coverage currently have vision insurance coverage?

Yes

No

If yes, applicant/family member name(s): ____________________________________________________________________________

Type of continuous coverage: Group

Individual

Other: __________________________________________________________

Insurance company: ___________________________________

Policy no. ____________________ Phoneno. __________________

Date coverage began:

Date ended:

(MM/DD/YY)

E. Is any person applying for coverage eligible for Medicare or currently receiving Medicare benefits?

Yes

No

Note: If you are eligible for Medicare, Anthem may not duplicate Medicare benefits.

Section 7: Medicare — Complete if you, your spouse or dependent child(ren) have Medicare coverage. Attach additional sheets if necessary.

Section 8: Prior coverage for PPO and dental plans only — Attach additional sheets if necessary.

Please fill out the following information to receive proper credit for previous coverage (if immediately prior to becoming eligible for this plan, you have a dependent child(ren) over the age of 26 who cannot get a self-sustaining job due to a physical or mental condition and was covered under any public or private health care coverage, including MediCal or individual coverage). Note: If this section is left blank, there may be delays in the processing of claims for these dependents. If any coverage will remain in force once your dependent(s) enroll with Anthem, leave the end date blank.

Coverage

Reason for

Type

(check all

Date (if applicable)

ending coverage

Name (last, first, M.I.)

(check one)

that apply)

Carrier name

Carrier phone no.

Policy ID no.

(MM/DD/YY)

(if applicable)

Individual

Health

Start:

Group

Dental

Medicare

Orthodontia

End:

Individual

Health

Start:

Group

Dental

Medicare

Orthodontia

End:

Individual

Health

Start:

Group

Dental

Medicare

Orthodontia

End:

1AnthemisrequiredbytheInternalRevenueServicetocollectthisinformation.

GC4050 Rev. 5/17 (effective date 10/17)

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Social Security or ID no.1 (required)

Section 9: Life insurance beneficiary designation information

Note: Dependent Life payments are always paid to the employee.

Primary Beneficiary — First to receive payment (required) If two beneficiaries are named, enter a % for each. If no % is shown, equal shares are assumed.

Section 10: Please read carefully — Signature required.

I attest by signing below that I have reviewed the information provided on this application and to the best of my knowledge and belief, it is true and accurate with no omissions or misstatements.

Deduction authorization: If applicable, I authorize my employer to deduct from my wages the required subscription charges/premiums.

Non-participating provider: I understand that I am responsible for a greater portion of my medical costs when I use a non-participating provider.

HIV testing prohibited: California law prohibits an HIV test from being required or used by health insurance companies as a condition of obtaining health insurance.

Effective date: The effective date of coverage is subject to Anthem approval.

COBRA/Cal-COBRA Continuation Coverage

You may continue your health care coverage by: 1) completing the remainder of this form; 2) signing your name in the blank space below; 3) paying your Total Monthly Continuation Payment; and 4) mailing this form to Anthem, no later than sixty (60) days after the date you receive this notice. If you fail to choose COBRA Continuation Coverage within sixty (60) days after the date you receive this notice, your qualification for coverage will end. If you do choose COBRA Continuation Coverage, your current coverage will be continued until the earliest of the following dates:

1 The date eligibility for COBRA Continuation Coverage ends, or

2The date you fail to make timely payments of your premium for COBRA Continuation Coverage, or

3 The date your employer discontinues coverage with Anthem, or

4 The date you become entitled to Medicare on the basis of age (65 years), or the date thirty (30) months after you become entitled to Medicare on the basis of end stage renal disease, or

5 The date you become covered under another group health plan as a result of employment, re-employment, remarriage, or otherwise.

If, at any time during the first sixty (60) days of your COBRA Continuation Coverage, you are determined under Title II or XVI of the United States Social Security Act to be disabled, you may be entitled to continue coverage while you are disabled for up to 29 months from the date you first qualified for Continuation Coverage under COBRA. Contact the Health Plan Administrator at your previous employer for full information.

The Monthly Continuation Payment is the cost of continued coverage for the month beginning on the date after the Date of Loss of Coverage. If you do not pay your initial monthly premium within 45 days after your election of COBRA Continuation Coverage, or if payment of succeeding premiums are not received within the 30-day grace period thereafter, your coverage will end.

Note: If you do not elect available COBRA Continuation of Medical Coverage, you will lose certain rights under federal law (HIPAA) to guaranteed issue individual coverage.

Electronic notice: By signing the field below labeled “Signature (Required)” I’m also consenting to get information about my benefits by email or electronically. This may include my certificate or evidence of coverage, explanation of benefits statements, required notices and helpful or personalized information to get the most out of my plan, so I will make sure Anthem has my most up to date email. These electronic communications may include specific details about me and my plan. I know I can change my mind at any time or request a free copy of specific materials by mail. I’ll just contact Anthem to

do either.

I certify each Social Security number listed on this application is correct.

REQUIREMENT FOR BINDING ARBITRATION (Not applicable to Life and Disability coverage)

ALL DISPUTES BETWEEN YOU AND ANTHEM BLUE CROSS AND/OR ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (ANTHEM), INCLUDING BUT NOT LIMITED TO DISPUTES RELATING TO THE DELIVERY OF SERVICE UNDER THE PLAN/POLICY OR ANY OTHER ISSUES RELATED TO THE PLAN/POLICY AND CLAIMS OF MEDICAL MALPRACTICE, MUST BE RESOLVED BY BINDING ARBITRATION, IF THE AMOUNT IN DISPUTE EXCEEDS THE JURISDICTIONAL LIMIT OF SMALL CLAIMS COURT AND THE DISPUTE CAN BE SUBMITTED TO BINDING ARBITRATION UNDER APPLICABLE FEDERAL AND STATE LAW, INCLUDING BUT NOT LIMITED TO, THE PATIENT PROTECTION AND AFFORDABLE CARE ACT. California Health and Safety Code Section 1363.1 and Insurance Code Section 10123.19 require specified disclosures in this regard, including the following notice: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as permitted and provided by federal and California law, including but not limited to, the Patient Protection and Affordable Care Act, and not by a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration. YOU AND ANTHEM AGREE TO BE BOUND BY THIS ARBITRATION PROVISION. YOU ACKNOWLEDGE THAT FOR DISPUTES THAT ARE SUBJECT TO ARBITRATION UNDER STATE OR FEDERAL LAW THE RIGHT TO A JURY TRIAL, THE RIGHT TO A BENCH TRIAL UNDER CALIFORNIA BUSINESS AND PROFESSIONS CODE SECTION 17200, AND/OR THE RIGHT TO ASSERT AND/OR PARTICIPATE IN A CLASS ACTION ARE ALL WAIVED BY YOU. Enforcement of this arbitration clause, including the waiver of class actions, shall be determined under the Federal Arbitration Act (“FAA”), including the FAA’s preemptive effect on state law. By providing your “handwritten or electronic” signature below, you acknowledge that such signature is valid and binding.

1AnthemisrequiredbytheInternalRevenueServicetocollectthisinformation.

GC4050 Rev. 5/17 (effective date 10/17)

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