Enrollment Form - Blue Cross Blue Shield of Massachusetts

Dental Blue ® HealthySupplement Enrollment FormEnrollee InformationFor Service Benefit PlanEnrollees OnlyTo enroll in Dental Blue Healthy Supplement,you must reside in Massachusetts.Are you a new Service Benefit Plansubscriber for 2009? Yes NoIf you are a new Service Benefit Plansubscriber for 2009, please include acopy of your SF 2809 form if available.Enrollment FormLast Name First Name Initial Date of Birth Social Security NumberStreet Address FEP ID Number Enrollment Code(Current Service Benefit Plan Subscribers Only)R/ / – –CityEmploying AgencyState Zip Work Phone Number Home Phone NumberSelect CoveragePlease note: You must select the same typeof enrollment that you currently have in theService Benefit Plan.check one:Self OnlySelf + OneFamily (3+)List your spouse and/or dependent children below. Only the dependents enrolled under your Service BenefitPlan coverage are eligible to enroll in Dental Blue Healthy Supplement.Date Social Sex Last NameFirst Name Initial of Birth Security Number (M/F) (if different) RelationshipIf you need to list more dependents, please attach an additional sheet.Please read and complete reverse side.5Blue Cross Blue Shield of Massachusetts is an Independent Licenseeof the Blue Cross and Blue Shield Association. ® Registered Marksof the Blue Cross and Blue Shield Association. © 2008 Blue Cross andBlue Shield of Massachusetts, Inc., and Blue Cross and Blue Shieldof Massachusetts HMO Blue, Inc.

Enrollment PeriodAs long as you remain eligible for enrollment inDental Blue Healthy Supplement, your enrollmentperiod is for the entire calendar year. Dental BlueHealthy Supplement benefits are based uponyear-long premiums. (For federal employees hiredduring the calendar year, the enrollment period andtotal premium liability are determined based on theeffective date of enrollment.) If you cancel yourDental Blue Healthy Supplement coverageduring the year by ceasing to pay premiumsor by requesting a mid-year cancellation, youwill not be able to re-enroll during the nextthree Open Seasons.Mail This FormMail the completed form to:Blue Cross and Blue Shield of MassachusettsDental Blue Healthy SupplementEnrollment DepartmentP.O. Box 55380Boston, MA 02205-8338Payment InformationBlue Cross and Blue Shield of Massachusetts, Inc., is authorized to bill me monthly for the premiumsfor Dental Blue Healthy Supplement.Please check:o Please bill me monthly, in advance, for my dental premiums.SignatureI Understand . . .These benefits are neither offered nor guaranteedunder the FEHB Program, but are made availableto all enrollees and dependents who are membersof the Service Benefit Plan and live in the servicearea of Blue Cross and Blue Shield of Massachusetts,Inc. The cost of these benefits is not included inthe FEHB premium, and charges for these servicesdo not count toward any FEHB deductibles orcatastrophic protection benefits. These benefitsare not subject to the FEHB disputedclaims procedures.I acknowledge and agree:• that coverage shall become effective only afterthis application is approved by the Plan and shallbe only as stated in the contract issued by thePlan; andDate• that any health care provider having informationor records pertaining to me or any covered familymember is authorized and directed to furnish suchinformation or records at the Plan’s request; and• that each response in this application has beenentered by me or at my direction and may be usedby the Plan to determine eligibility of me and anyfamily member for this coverage and that, if I havemisstated or omitted any material information, thePlan may declare such coverage null and void fromits issuance; and• that I will pay premiums as stated in the brochure.SignatureDate6