BlueFund CDH - BluePreferred - 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 BluePreferred BlueFund Enrollment Form (even if they are currently enrolled in a BluePreferred 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 BluePreferred HSA  
N/A
MSGR (2-50) BluePreferred HSA Compatible and HRA Compatible and BlueFund Plans  
N/A
N/A
2-24 NON-MSGR BlueFund BluePreferred HRA  
2-24 NON-MSGR BlueFund BluePreferred HSA  
2-24 NON-MSGR BluePreferred HSA or HRA Compatible Plans  
N/A
25+ NON-MSGR BlueFund BluePreferred HRA  
25+ NON-MSGR BlueFund BluePreferred HSA  
25+ NON-MSGR BluePreferred 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 BluePreferred HRA  
2-24 BlueFund BluePreferred HSA  
2-24 BluePreferred HSA or HRA Compatible Plans  
N/A
25+ BlueFund BluePreferred HRA  
25+ BlueFund BluePreferred HSA  
25+ BluePreferred HSA or HRA Compatible Plans  
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 BluePreferred HRA  
2-24 BlueFund BluePreferred HSA  
2-24 BluePreferred HSA or HRA Compatible Plans  
N/A
25+ BlueFund BluePreferred HRA  
25+ BluePreferred HSA or HRA Compatible Plans  
N/A
25+ BlueFund BluePreferred HSA  

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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