X
	
Hire/RehireDat
	
e
	
Retire
	
d Eff
	
ectiv
	
eDa
	
te

Dental Group #
								
Subgroup #

Wastheemployeesubjecttoawait If yes, what was thestartdate:
	
ingp
	
e
	
riodbeforeenrollinginyo
	
uremployerhea and enddate:
			
					lthplan?
			No
		Yes

																		
	
2 – Subscriber Plan Selection
	Department#
												Employee#
													
Please use blue or black ink, print one character per box. Check applicable plan(s).
	
Medical
GAHP PPO With Drug (GA) GAHP D2 With Drug(P7) GAHP PPO Without Drug(GA) GAHP D2 Without Drug(P7)
GAHP HealthyBlue HDHP With Drug(DAG)
	Dental
GAHP DentalBlueBasic (EBD) GAHP DentalBlueSelect (EBC) GAHP DentalBlue Premier (EBH)
	Vision
*See Davis Vision Form to Enroll
	Please check coverage type & person(s) to be covered: Medical
Single Sub & spouse Sub& dependents Family Dental
Single Family
Vision (see Davis Vision Enrollmentform)
	
3 – Reason for Enrollment/Change
		
Subscriber, please indicate the reason for this enrollment or change.

GENESEE AREA HEALTHCARE PLAN GROUP ENROLLMENT FORM

P.O. Box 22999, Rochester, NY 14692	DO NOT USE –FOR INTERNAL USE ONLY A nonprofit independentlicensee of the BlueCrossBlueShield Association

Instructions on last page. All Dates = mm/dd/yy

	1 – Group Employer Information
	PLEASE PRINT CLEARLY
	
	This section should becompleted by theGroup Benefits Administrator.
		
	This application cannot be processed without this information and asignature.

Please use blue or black ink, print one characterperbox	SubscriberStatus:

Group#	Subgroup #	Class#	Active	Retired	COBRA	Cancelled

0
	0
	0
	4
	4
	3
	2
	9

Please indicate reason for COBRA:

EmployerName

Genesee Area Healthcare Plan

Association/Chamber Name(ifapplicable)

Group Administrator Signature/Date

LeftEmploy/Retirement

Divorce/LegalSeparation

Loss ofStudent Status

Effective Date

Death ofSpouse

Dependent Reached MaxAge

Other 	

COBRA EffectiveDate

New Hire	Add Dependent (Please indicate reason for adding dependent) Open Enrollment                                Newborn
COBRA	Adoption Address/Phone Number Change	Marriage Name Change _____________________(reason for change)
Remove Dependent	Marital Status Change	Loss of Coverage

Medicare Eligibility (Please indicate reason for Medicare eligibility) Age 65+
Disability Retirement
End Stage Renal Disease

4 – Subscriber Information – AS SHOWN ON SOCIAL SECURITY CARD.
		
Please complete both sidesof this application. Thesubscriber signature is requiredin order to process the application.

Subscriber’sLast Name	Subscriber’s FirstName

MiddleInitial	Title	E-mailAddress

MailingAddress	Apt orSuite

City	State	Zip

WorkPhone Number
-	-

HomePhone Number
/	-	-

Cell PhoneNumber
/	-	-

Dateof Birth

MaritalStatus:

Gender M

Single	Married

	F

SocialSecurityNumber

-	-

LegallySeparated	Divorced/ Marital Status EventDate

FAP-143GAHP (9/10) 2012	Return Original to Excellus BlueCross BlueShield at above address – Copy: Employer Group

a fulltimestudent?
		
No
		
Yes If yes,
	
Any person who knowingly and with intent to defraudanyinsurancecompany
material thereto, commits a fraudulentinsurance act, whichis a crime, and shallalso be subject to a civil penalty not to exceed $5,000 an
Medicare Number(ifapplicable)	Part A EffectiveDate	Part B EffectiveDate

If Medicare eligible due to ESRD please check typeofdialysis:	Self administered	Facilitated Datestarted:
										
5 – Other Coverage Information
	Have you ever been a member of ExcellusBlueCrossBlueShield?
		Yes
		No
	
In addition, please provide a copy of your “Certificate of Coverage” from your former health insurance carrier
	oremployer.
	
Haveyou,yourspouseor anyenrolleddependenthadothercoveragewithinthelast63days? Health?
		No
		Yes / Dental?

Y
		No
		Yes

If answering “Yes”, are you keeping the additional health and/or dentalcoverage? Health?	No
		
Yes / Dental?	No
			
es

	Spouse
		Children

	

Who did the otherplancover?	Self Other insurance carriername:
Other insurance name of policyholder:

PolicyIDNumber:	EffectiveDate	TerminationDate

6 – Cancellation Information
		
Please indicate who is being cancelled and the reason for cancellation (reason listing on page 4).
	
Subscriber
		Medical
		Dental	Reason	               Date

Dependent (list each dependent insection7)
		Medical	Dental	Reason	Date
	
7 – Dependent Information
		
Please provide all information for each person to be covered. (AS SHOWN ON SOCIAL SECURITY CARD)

Subscriber’sLast Name	Subscriber’s First Name

Spouse's LastName	Spouse'sFirstName	M.I.

																
	
Male	DateofBirth	Social SecurityNumber
Female	-

-

Medicare Number(ifapplicable)	Part AEffectiveDate	Part B EffectiveDate

Dependent’sLastName

Male	DateofBirth	Social SecurityNumber
Female	-	-

Dependent’sFirstName	M.I.

Is your over-age dependent handicappedordisabled?

Yes	No (See last page for additionalinformation)

Is Dependent College/UniversityName

please indicate college/universityname:
ExpectedGraduationDate	Credithours

Dependent’sLastName

	
Male	DateofBirth	Social SecurityNumber
Female	-	-

Dependent’sFirstName	M.I.

Is your over-age dependent handicappedordisabled?

Yes	No (See last page for additionalinformation)

											
a fulltimestudent?
		No
		
Yes If yes,
	
Is Dependent	please indicate college/universityname:

College/UniversityName	ExpectedGraduationDate	Credithours

8 – Release/Signature
		
Subscriber signature required. You must sign and date this form to be eligible forinsurance.
	
or other person files an application forinsurance or statement ofclaim containingany materially false information, or conceals for the purposeof misleading,informationconcerningany factd the stated value of theclaim for eachsuchviolation. I have thoroughly read,understandand agree to comply with theterms of the Release on the back.
Subscriber Signature	Date	

FAP-143GAHP (9/10) 2012	Return Original to Excellus BlueCross BlueShield at above address – Copy: Employer Group

a fulltimestudent?
		
No
		
Yes If yes,

a fulltimestudent?
		
No
		
Yes If yes,

a fulltimestudent?
		No
		Yes If yes,

a fulltimestudent?
		
No
		
Yes If yes,

a fulltimestudent?
		
No
		
Yes If yes,
	
GENESEE AREA HEALTHCARE PLAN P.O. Box 22999, Rochester, NY 14692	GROUP ENROLLMENT FORM
Asso
A nonprofit independent licensee of the BlueCross BlueShield ciation Instructions on last page. All Dates = mm/dd/yy

DO NOTUSE –FOR INTERNAL USE ONLY

9 – Additional Dependents
	PLEASE PRINT CLEARLY
	
Please provide all information for each person to be covered. (AS SHOWN ON SOCIAL SECURITY CARD)

Subscriber’sLast Name

Dependent’sLastName

	
Male	DateofBirth	Social SecurityNumber
Female	-	-

Subscriber’s First Name

Dependent’sFirstName	M.I.

Is your over-age dependent handicappedordisabled?

Yes	No (See last page for additionalinformation)

Is Dependent College/UniversityName

please indicate college/universityname:
ExpectedGraduationDate	Credithours

Dependent’sLastName

	
Male	DateofBirth	Social SecurityNumber
Female	-	-

Dependent’sFirstName	M.I.

Is your over-age dependent handicappedordisabled?

Yes	No (See last page for additionalinformation)

Is Dependent College/UniversityName

please indicate college/universityname:
ExpectedGraduationDate	Credithours

Dependent’sLastName

	
Male	DateofBirth	Social SecurityNumber
Female	-	-

Dependent’sFirstName	M.I.

Is your over-age dependent handicappedordisabled?

Yes	No (See last page for additionalinformation)

Is Dependent College/UniversityName

please indicate college/universityname:
ExpectedGraduationDate	Credithours

Dependent’sLastName

	
Male	DateofBirth	Social SecurityNumber
Female	-	-

Dependent’sFirstName	M.I.

Is your over-age dependent handicappedordisabled?

Yes	No (See last page for additionalinformation)

Is Dependent College/UniversityName

please indicate college/universityname:
ExpectedGraduationDate	Credithours

Dependent’sLastName

	
Male	DateofBirth	Social SecurityNumber
Female	-	-

Dependent’sFirstName	M.I.

Is your over-age dependent handicappedordisabled?

Yes	No (See last page for additionalinformation)

Is Dependent College/UniversityName

please indicate college/universityname:
ExpectedGraduationDate	Credithours

FAP-143GAHP (9/10) 2012	Return Original to Excellus BlueCross BlueShield at above address – Copy: Employer Group

Reason for Enrol ment/Change: Check the appropriate action in the space provided. An event is a specific occurrence, due to change in status,
see your Group Administrator/Representative for events that fall outsde the 30-day period. If New Hire, Open Enrollment, Add/Remove Dependent or
Loss of Coverage, you must also check coverage type and persons to be covered, and Dependent Information section.
Group Enrollment Form:
Group Enrollment Form:
 indica e Cancelaton Date in spaceprovided
 indica e Cancelaton Date in spaceprovided
 complete Subscriber nformation
Cancel Subscriber Reasons
Cancel Dependent Reasons
COBRA Begin Date
Transferto Traditional
Transfer to POS
Commercial	Subscriber Reque
Subscriber Deceased
Medicaid
Deceased
Dependent Over Age	Subscriber Request
Divorce
Complete only he coveragesection (Medical/Dental) that is applicable to the employee's request.
Instruction Page
marriage, divorce,lbirth or adoption, group's anniversary date, or ratei change. Your request must be received within 30 days of the event date. Please

Cancel Request
To process a Subscriber or Dependent cancellation, please use the Membership Cancellation Worksheet - OR -
	
To Cancel an Employee/Subscriber using the

 check Subscriberbox
 checkt Productsl toi be cancelled (Medical,Dental)
 complete SubscriberInformation

Left Employer/No LongerEligible	COBRA End Datest

COBRA Handicapped/Disabled Date	Spouse's Insurance

Transfer to HMO	Medicare
	To Cancel a Dependentusing the

 check Dependentbox
 checktProductsl toi beIcancelled (Medical,Dental)
 complete Dependent Name and Dependent Birthdate

Marriage – when permitted by law COBRA BeginDate

Ineligible Student	Medicare
	
COVERAGE TYPE All products may not be applicable to your employer group. Please check with your Group Administrator/Representative.
	
SUBSCRIBER If you or your dependents are Medicare eligible, complete the questions regarding Medicare Coverage.
	
FAMILY MEMBER INFORMATION If there are more than seven dependents please use an additional form. QUALIFIED GUIDELINES:
A legal spouse (an ex-spouse is not a qualified member as of the divorce date) Must be under the eligible child age for your employer group:
- natural, adopted or stepchild
Other: Please contact your Group Administrator/Representative for the appropriate form. These dependents have additional eligibility requirements. Dependents pending adoption,for whom you are the legal guardian, and/or a handicapped or disabled dependent who isover the dependent age for your employer group.
	
RELEASE
	Iamapplyingtoenrollmyselfandmyeligibledependents,ifany,underthe medicaland/ordentalcontract.
	In the eventthat a premiumcontribution is required of me, Iagree to paythe premium amountsapplicable to the contract under which Iam covered. I authorize my employer to deduct from my payroll such applicable amountsand to remit them to Excellus BlueCrossBlueShield.
	Ifthisapplication ismadeon behalfofaminor,theresponsiblepartymustcompletetheapplication.
	Byacceptingthiscontract,Igrantpermission toExcellusBlueCrossBlueShieldto submitchargestoand/orrecoverpayment from anyother insurance carrier acting as myprimaryinsurer.
	I authorize Excellus BlueCross BlueShield to request and receive medicalor dental information regarding me or my covered dependentsfrom my healthcare practitioneror healthcare institution either orally orin writing and to use this information for providing coverage.Providing coverage includes:processing claims, reviewing grievances or complaints involving care and quality assurance reviewsof care, whether based on a specific complaint ora routine auditof randomly selected cases. In the use of data for these purposes, we may transmit personal information to third parties with which we contract, including pharmacy benefit managers, disease management vendors orsurveyors.
	Iherebyrepresentthatallinformationfurnishedbymehereon istrue andcompleteto thebestofmyknowledge. 	PREFERRED PROVIDER ORGANIZATION(PPO)
I understand that the Preferred Provider Organization (PPO) coverage is comprised ofan in-networkbenefit that is dependent on the utilization of medical providers who participate with the PPO and an out-of-network benefit which provides coverage for services of medical providers who do notparticipate with the PPO. I understand thatthe in-network benefit provides the highest level of coverage under the plan.
	The certificate or contract for which application is being made may impose a waiting period ofup to twelve (12) months for preexisting conditions, subject to the provisions ofapplicable law including creditable coverage requirements. The certificate or contract document will describe anyapplicable waitingperiods.
	
GROUP EMPLOYER INFORMATION This section tto be completed and signed by the Employer Group Administrator/Representative.

If you have any questions,please contact your Group Administrator/Representative. Or, visit us at: www.excellusbcbs.com

FAP-143GAHP (9/10) 2012	Return Original to Excellus BlueCross BlueShield at above address – Copy: Employer Group