Name(s) of Dependent(s) on BCBS Policy
Social Security # (Optional)
No Dependent(s) on BCBS Policy
If this does not apply, skip to Section C.
Check those that apply:
Other Health Insurance
Other Dental Insurane
What type of policy is this?
Other Insurance Carrier's Name:
Dependent(s) listed on the other insurance
Effective or Cancel Date, if different from policyholder:
Other Insurance Policyholder’s Name:
Policyholder’s Date of Birth:
Effective Date of Other Insurance:
If Cancelled, Cancellation Date:
Is the policyholder:
Actively working for the group
Retired, retirement date
on COBRA, which began
If this does not apply, skip to Section D.
Do the policyholder and/or dependent(s) have Medicare?
Name of person(s) with Medicare:
Medicare Number, including alpha character(s):
Effective Date of Medicare Part A:
Effective date of Medicare Part B:
Effective date of Medicare Part C:
Effective date of Medicare Part D:
End Stage Renal Disease (ESRD)
*If the reason is for Disability or ESRD, please provide the following:
1st Date of Disability:
1st Date of Dialysis for ESRD:
Was ESRD started in a facility?
Was ESRD started as Self Dialysis or Home Dialysis:
Has a transplant been performed?
If yes, please provide the date of the transplant.
In addition, please provide a copy of the Medicare Card
Court Order Information
Is there a Court Order specifying a person(s) who must maintain health coverage for any of your dependent(s)?
List the name(s) of the dependent(s) to whom the Court Order applies:
If yes, who is the person(s) listed to maintain health coverage?
What is the relation to the child(ren)?
Who has custody of the child(ren) more than 50% of the time?
Documentation of the court order may be requested from your Blue Cross Blue Shield plan