Subscriber Change Request Blue Shield of California and Blue Shield of California Life & Health Insurance Company Please fill in circles (selections) as opposed to inserting a check mark All changes must be received within 31 days of the effective date of change This form cannot be used for primary care physician (PCP) changes - subscriber must call plan directly Employee identification this section must be completed Subscriber ID number (from ID card) Group number (from ID card) Work telephone Home telephone Home street address City State Zip code Group/employer name (if applicable) E-mail address Changes O Yes Is this a change/correction of address? O Yes Is the change/correction of address for a dependent? If yes, please indicate dependent name and address change: Home street address City State Zip code O Requested effective date: O Correct my to: (Copy of Social Security card, a photo ID, a letter of verification from the Social Security office, and a written statement of why the employee is requesting the change must be attached) O This is a change made during open enrollment C675-1-ML (8/11) Subscriber change request 1 of 5
O Transfer/add my health coverage to: O HM PP POS O Active Choice * O Shield Savings Plus O CORE FLEX Value Transfer my specialty benefits coverage to: O DHM DPP DINO From Group No - to Group No - in my employer group Note: If transferring coverage to HMO, POS, or DHMO, please complete Section A O Change the amount of my Supplemental Life and AD&D insurance coverage: Prior amount of coverage: O Correct/change name to: Last name New amount of coverage: First name O Correct/change email address to: O Correct/change my date of birth from: to: O itional changes/comments: O Subscriber cancellation: I decline health plan coverage for myself (and dependents, if any) effective: O COBRA participant O Qualifying event: O Is this a termination? If yes, list name(s): Dependent coverage changes dependent(s) Complete section A Requested effective date for additions: O Date of marriage if adding spouse: O Domestic partner date of domestic partnership if adding: O If court ordered custody/coverage, enter date and attach copy of legal documents: O If adoption, enter date of adoption or date placed for adoption, and attach copy of legal documents: O Change the Supplemental Life and AD&D insurance coverage amount of the spouse or domestic partner: (provide prior coverage amount and new coverage amount) Prior amount of coverage: New amount of coverage: C675-1-ML (8/11) Subscriber change request 2 of 5
dependent(s) Complete section A O Requested effective date for deletions: For cancellation of spouse or domestic partner: (select appropriate cancellation reason and provide date of event) O Divorce or termination of domestic partnership O Death ther reason (please specify) Other reason date: For cancellation of dependent children: (select appropriate cancellation reason and provide date of event) O Death ther reason (please specify) Other reason date: Please provide a copy of the HIPAA certificate if enrolling self and/or dependent(s) who are age 19 or older as a health plan participant during open enrollment (OE), or if you are adding dependent(s) to your coverage outside OE with a qualifying event Qualifying event: Qualifying event date: Note: Newborn/adopted children or children placed for adoption require a completed Subscriber Change Request to be submitted within 31 days from the date of birth/adoption/placement for adoption to be added to your coverage Please be sure to return all pages of this form as the last page contains your signature which is necessary to process these changes Section A Complete this section if adding/canceling coverage for yourself or your dependents Provide Personal Physician/Dental provider information if the change pertains to HMO/POS/DHMO coverage Please fill in which benefit the change applies to: Self Date of birth (mm/dd/yyyy) Sex O Life 1 O Life 1 If adding Life and AD&D insurance please indicate amount O Supp Life 1 O Supp Life 1 C675-1-ML (8/11) Subscriber change request 3 of 5
spouse/domestic partner Date of birth (mm/dd/yyyy) Sex O Life 1 O Life 1 If adding Life and AD&D insurance please indicate amount O Supp Life 1 O Supp Life 1 Child Date of birth (mm/dd/yyyy) Sex O Life 1 O Life 1 O Supp Life 1 O Supp Life 1 (note: all children will be covered for the same amount ($5,000 or $10,000) C675-1-ML (8/11) Subscriber change request 4 of 5
Child Date of birth (mm/dd/yyyy) Sex Child Date of birth (mm/dd/yyyy) Sex All information I have provided on this form is accurate and complete I understand that this form, along with any prior enrollment form, the Evidence of Coverage/Certificate of Insurance and Health Service Agreement/policy, and any endorsements and attachments thereto, collectively constitutes the entire agreement for coverage Employee Signature If faxing this form, keep this document for your files Blue Shield of California/Blue Shield Life protects the confidentiality and privacy of your personal and health information Personal and health information includes both medical information and individually identifiable information, such as your name, address, telephone number, and We will not disclose this information, except as permitted by law Please be sure to return all pages of this form as this page contains your signature which is necessary to process these changes C675-1-ML (8/11) Subscriber change request 5 of 5 Date * Underwritten by Blue Shield of California Life & Health Insurance Company (Blue Shield Life) Pending regulatory approval 1 Evidence of Insurability form may be required blueshieldcacom An Independent Member of the Blue Shield Association