Notes
- Forms and applications inside gray-shaded boxes must be ordered by calling (202) 479-8595 or your CareFirst Sales Representative.
- All other forms can be ordered by contacting the Literature Resource Center.
- Viewing and printing these documents requires Adobe Acrobat.
- 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.
|
|
Notes below are applicable to group contracts effective 4/1/04 and after:
Additional instructions for completing Enrollment Forms are available in the Miscellaneous Forms - "For Brokers" section on carefirst.com.
** MD Groups: If a group chooses BlueChoice medical coverage (BlueChoice, BlueChoice Opt-Out, BlueChoice Opt-Out Open Access, or BlueChoice Opt-Out Plus) and indemnity dental coverage (Traditional or Preferred), and elects to offer non-parallel enrollment for dental, the group will receive a GHMSI Non-Ridered Dental contract. In this case, the group is required to sign two Group Contract Applications (BlueChoice & GHMSI), unless the group selects a Point-of-Enrollment package, which only requires the signed Point-of-Enrollment Group Contract Application (Non-MSGR only). In this situation, an employee must complete two subscriber Enrollment Forms (BlueChoice & GHMSI).
*** DC and Virginia Groups: If a group chooses BlueChoice medical coverage (BlueChoice, BlueChoice Opt-Out, BlueChoice Opt-Out Open Access, or BlueChoice Opt-Out Plus) and indemnity dental coverage (Traditional or Preferred), and elects to offer non-parallel enrollment for dental, the group will receive a GHMSI Non-Ridered Dental contract. In this case, the group is only required to sign one Group Contract Application for the BlueChoice medical product. In this situation, the participation rules for the dental will follow the medical participation rules stated in the BlueChoice Group Contract Application. In this situation, an employee must complete two subscriber Enrollment Forms (BlueChoice & GHMSI).
Maryland:
|
Group Size
|
New Group Subscriber Enrollment Form
|
Subsequent Enrollee & Late Entrant Enrollment Form
|
|
Group Contract Application
|
Point of Enrollment
|
| 2-24 NON-MSGR |
|
|
|
|
|
| 25-50 NON-MSGR |
|
|
|
|
|
| 51+ NON- MSGR |
|
|
|
|
|
| Dental Freestanding & Non-Rider MSGR (2-50) |
|
|
|
|
N/A
|
| Dental Non-Rider Non-MSGR with Medical |
|
|
|
|
|
| Vision Non-Rider MSGR (2-50) |
|
|
|
|
N/A
|
| Vision Non-Rider Non-MSGR with Medical |
|
|
|
|
|
Virginia:
|
Group Size
|
New Group Subscriber Enrollment Form
|
Subsequent Enrollee & Late Entrant Enrollment Form
|
|
Group Contract Application
|
Point of Enrollment
|
| 2-24 (product other than VA E&S) |
|
|
|
|
|
| 25+ (product other than VA E&S) |
|
|
|
|
|
| VA E&S |
|
|
|
|
N/A
|
| Dental Freestanding & Non-Rider (product other than VA E&S) |
|
|
|
|
|
| Vision Freestanding & Non-Rider (product other than VA E&S) |
|
|
|
|
|
| Dental Non-Rider (VA E&S) |
|
|
|
|
N/A
|
District of Columbia:
|
Group Size
|
New Group Subscriber Enrollment Form
|
Subsequent Enrollee & Late Entrant Enrollment Form
|
|
Group Contract Application
|
Point of Enrollment
|
| 2-24 |
|
|
|
|
|
| 25+ |
|
|
|
|
|
| Dental Freestanding & Non Rider |
|
|
|
|
|
| Vision Freestanding & Non Rider |
|
|
|
|
|
 |
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. |
|
|
This site is best viewed in IE 5.0 or higher or Netscape 7.0 or higher. |
|
|
