BlueFund CDH - BlueChoice HMO Open Access -
Group and Member Forms and Applications


Notes

  1. Applications and forms inside gray-shaded boxes must be ordered by calling (202) 479-8595 or your CareFirst Sales Representative.
  2. All other forms can be ordered by contacting the Literature Resource Center.
  3. Viewing and printing these documents requires Adobe Acrobat.
  4. If you do not already have this program, you can download it free from the Adobe site.

Instructions

Download Single Form:
Use the grid below to download and print a form*.

Ordering Multiple Copies:
Please contact your CareFirst Sales Representative.

Note: If the group is adding a BlueFund HSA or HRA at renewal or purchasing it as a new group, the group must complete the new FlexAmerica application. This application must be attached to either the new or renewing group paperwork that will be sent to CareFirst Account Installation.

Groups choosing to enroll in a BlueFund HSA product must complete a New Group Subscriber Enrollment Form (even if they are currently enrolled in a BlueChoice product.)


Group Size
New Group Subscriber Enrollment Form
Subsequent Enrollee & Late Entrant Enrollment Form
 
Group Contract Application
Point of Enrollment
FlexAmerica Application
MSGR (2-50) BlueFund BlueChoice HSA  
N/A

FlexAmerica HSA
MSGR (2-50) BlueChoice HSA Compatible Plan
N/A
N/A
2-24 NON-MSGR BlueFund BlueChoice HSA
2-24 NON-MSGR BlueChoice HSA or HRA Compatible Plans
CUT5609 
(electronic version only)
N/A
2-24 NON-MSGR BlueFund BlueChoice HRA
CUT5609 
(electronic version only)
25-50 NON-MSGR BlueFund BlueChoice HSA (electronic version only)
25-50 BlueChoice HSA or HRA Compatible Plans (multi-ply form)
FGE5128
(must be ordered)
FGE5128
(must be ordered)
N/A
25-50 NON-MSGR BlueFund BlueChoice HRA (electronic version only)
51+ NON-MSGR BlueFund BlueChoice HSA (electronic version only)
51+ NON-MSGR BlueChoice HSA or HRA Compatible Plans (electronic version only)
N/A
51+ NON-MSGR BlueFund BlueChoice HRA (electronic version only)
51+ NON-MSGR BlueFund BlueChoice HSA (multi-ply form)
FGE5141
(must be ordered)
FGE5141
(must be ordered)
51+ NON-MSGR BlueChoice HSA or HRA Compatible Plans (multi-ply form)
FGE5128
(must be ordered)
FGE5128
(must be ordered)
  
N/A
51+ NON-MSGR BlueFund BlueChoice HRA (multi-ply form)
FGE5128
(must be ordered)
FGE5128
(must be ordered)
  

Virginia:

Group Size
New Group Subscriber Enrollment Form
Subsequent Enrollee & Late Entrant Enrollment Form
 
Group Contract Application
Point of
Enrollment
FlexAmerica Application
2-24 BlueFund BlueChoice HSA (product other than VA & ES)  
2-24 BlueChoice HSA or HRA Compatible Plans (product other than VA & ES)
N/A
2-24 BlueFund BlueChoice HRA (product other than VA & ES)
25+ BlueFund BlueChoice HSA (product other than VA & ES)
25+ BlueChoice HSA or HRA Compatible Plans (product other than VA & ES)
N/A
25+ BlueFund BlueChoice HRA (product other than VA & ES)  

District of Columbia:

Group Size
New Group Subscriber Enrollment Form
Subsequent Enrollee & Late Entrant Enrollment Form
 
Group Contract Application
Point of
Enrollment
FlexAmerica Application
2-24 BlueFund BlueChoice HSA  
2-24 BlueChoice HSA or HRA Compatible Plans
N/A
2-24 BlueFund BlueChoice HRA
25+ BlueChoice HSA or HRA Compatible Plans
N/A
25+ BlueFund BlueChoice HSA
25+ BlueFund BlueChoice HRA  

Adobe Acrobat PDF Viewing and printing this document requires Adobe Acrobat Reader, which can be downloaded free from the Adobe site.

Serving Maryland, the District of Columbia and portions of Virginia. CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc.

CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are independent licensees of the Blue Cross and Blue Shield Association.

® Registered trademark of the Blue Cross and Blue Shield Association. ®' Registered trademark of CareFirst of Maryland, Inc.
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