BlueFund CDH - BlueChoice Opt-Out Plus Open Access -
Group and Member Forms and Applications


Notes

  1. Forms and applications 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.)


Maryland:

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 Opt-Out Plus HSA  
N/A
MSGR (2-50) BlueFund BlueChoice Opt-Out Plus HSA Compatible Plan  
N/A
N/A
2-24 NON-MSGR BlueFund BlueChoice Opt-Out Plus HRA  
2-24 NON-MSGR BlueFund BlueChoice Opt-Out Plus HSA  
2-24 NON-MSGR BlueChoice Opt-Out Plus HSA or HRA Compatible Plans  
N/A
25-50 NON-MSGR BlueFund BlueChoice Opt-Out Plus HRA  
25-50 NON-MSGR BlueFund BlueChoice HSA Opt-Out Plus  
25-50 BlueChoice Opt-Out Plus HSA or HRA Compatible Plans  
N/A
51+ NON-MSGR BlueFund BlueChoice Opt-Out Plus HSA  
51+ NON-MSGR BlueFund BlueChoice Opt-Out Plus HRA  
51+ NON-MSGR BlueChoice Opt-Out Plus HSA or HRA Compatible Plans  
N/A

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 Opt-Out Plus HRA (product other than VA & ES)  
2-24 BlueFund BlueChoice Opt-Out Plus HSA (product other than VA & ES)
CUT6912 (electronic version only)
  
2-24 BlueChoice Opt-Out Plus HSA or HRA Compatible Plans (product other than VA & ES)  
N/A
25+ BlueFund BlueChoice Opt-Out Plus HRA (product other than VA & ES)  
25+ BlueFund BlueChoice Opt-Out Plus HSA (product other than VA & ES) (electronic version only)  
25+ BlueChoice Opt-Out Plus HSA or HRA Compatible Plans (product other than VA & ES)  
N/A

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 Opt-Out Plus HRA  
2-24 BlueFund BlueChoice Opt-Out Plus HSA  
2-24 BlueChoice Opt-Out Plus HSA or HRA Compatible Plans  
N/A
25+ BlueFund BlueChoice Opt-Out Plus HRA  
25+ BlueFund BlueChoice Opt-Out Plus HSA  
25+ BlueFund BlueChoice Opt-Out Plus HSA or HRA Compatible Plans  
N/A

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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