Section 2 - Yourself (Member 1)
Please fill in all information that applies to you. (REQUIRED)*
PCP ID#—If your health plan requires you to choose a primary care physician (PCP), please fill in this section. Write the PCP ID number (not the telephone number)
of the doctor you have chosen to coordinate your health care. You’ll find the doctor’s PCP ID number in the provider directory for your health plan. If you need help choosing a PCP, please call our Physician Selection Service at 1-800-821-1388. A representative will be happy to help you select a doctor. PCP ID number can be found
at bluecrossma.com, select Find a Doctor.
Other Insurance—Do you have other health insurance or Medicare in addition to your Blue Cross Blue Shield plan? Please be sure to circle either Y (for yes) or N (for no) ) in the correct box. If you have other insurance, please write the name of the other insurance company and your member identification number.
To Add or Delete a Member—Are you adding or deleting a member under your existing membership? If yes, please fill in the areas in Sections 1 and 2. You may
need help from your employer to fill in Section 1. Then, give us the details about the members you’re adding or deleting in Section 3 and/or Section 4.
Section 3 - Member 2
If you choose a Family membership, please fill in this section if you want Member 2 to be covered. (REQUIRED)* (Note: Member 2 cannot be covered under an Individual membership.)
Other Insurance—Does your spouse have other health insurance or Medicare? Please be sure to circle either Y (for yes) or N (for no) in the correct box. If your spouse or partner has other insurance, please write the name of the other insurance company and your member identification number.
Section 4 - Your Eligible Dependents (Members 3, 4, and 5)
If you choose a Family membership, please fill in this section for all children or other eligible dependents you want to be covered. (REQUIRED)* (Note: dependents cannot be covered under an Individual membership.)
If you have more than three dependents to be covered, please use additional Enrollment Forms as needed. Please indicate on the form that additional forms have been used and write in the total number of dependents you want to be enrolled.
Section 5 - Personal Savings Account
Your employer may have chosen to offer a personal savings account alongside your medical offering. Please consult your open enrollment materials and/or your HR department to determine if this applies to you.
For each option:
Start Date: Your start date will be considered established for tax purposes as of the start date of your medical plan, provided that you have signed, dated, and submitted the completed application for these accounts on or before that date.
End Date: Your end date is the date you choose to stop deposits into the selected financial account. If you have any questions, please see your employer.
Note: If you are transferring from one medical/dental plan to another plan, please complete Section 5 of the Enrollment and Change Form to let us know that you will be continuing your personal savings account.
Section 6 - Signature (Employee)
Employee: Please sign and date the application and return it to your employer. Employer: Please sign and date the application and return to Blue Cross Blue Shield of Massachusetts.
Please mail to:
P.O. Box 986001
Boston, MA 02298
or fax to 1-617-246-7531
* Under the Affordable Care Act, we are required to collect the Social Security number for you and any dependent enrolling in your plan.
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