Anthem Blue Cross Enrollment Form Instructions
This file contains the enrollment form for Anthem Blue Cross, including detailed instructions on completing the form and submitting it. The form covers various types of coverage such as medical, dental, vision, and life insurance. It also provides sections for declination, COBRA/Cal-COBRA coverage, applicant's personal information, and prior coverage.
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How do I fill this out?
To fill out the Anthem Blue Cross Enrollment Form, carefully follow the instructions provided in each section. Ensure all required fields are completed accurately. If needed, attach additional sheets for more information before submitting the form to your employer.
How to fill out the Anthem Blue Cross Enrollment Form Instructions?
1
Read each section carefully and complete all required fields.
2
Indicate your type of coverage and provide personal information.
3
List eligible family members and their details in the Employee and Family Information section.
4
Sign and date the form where necessary.
5
Submit the completed form to your employer for submission to Anthem Blue Cross.
Who needs the Anthem Blue Cross Enrollment Form Instructions?
1
Employees enrolling in Anthem Blue Cross coverage for the first time.
2
Employees making changes to their existing Anthem coverage.
3
Employees adding family members to their coverage.
4
Employees enrolling in COBRA/Cal-COBRA coverage.
5
Employees declining any available coverage.
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Navigate to the field you need to update.
3
Click on the field and enter the necessary information.
4
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5
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What are the instructions for submitting this form?
To submit the completed Anthem Blue Cross Enrollment Form, return it to your employer. They will review it for completeness and then forward it to Anthem Blue Cross. You can also send the form directly to Anthem Blue Cross via mail at PO Box 629, Woodland Hills, CA 91365-0629, via fax at 1-818-234-2774 or 1-818-234-4482, or via email at CALGEnrollintake@wellpoint.com. Make sure to keep a copy of the submitted form for your records. It's important to adhere to any specified submission deadlines to ensure timely processing of your enrollment.
What are the important dates for this form in 2024 and 2025?
Important dates for this form include open enrollment periods, typically in the fall, with specific dates varying by employer. COBRA/Cal-COBRA coverage deadlines align with federal and state regulations, so check with your employer for exact dates.
What is the purpose of this form?
The purpose of the Anthem Blue Cross Enrollment Form is to enable employees to enroll in, make changes to, or decline their health coverage. This includes medical, dental, vision, and life insurance plans. By completing this form, employees can ensure they and their dependents receive the necessary benefits.
Tell me about this form and its components and fields line-by-line.
- 1. Type of Coverage: Select from the coverage options offered by your employer, including medical, dental, and vision plans.
- 2. Applicant's Personal Information: Provide your personal details such as name, social security number, address, and employment details.
- 3. Employee and Family Information: List yourself and all eligible family members to be enrolled, including their personal information.
- 4. Declination: Complete this section if you are declining any coverage for yourself or your dependents and state your reason.
- 5. COBRA/Cal-COBRA Coverage Information: If enrolling in COBRA/Cal-COBRA, provide the necessary event and coverage dates.
- 6. Other Coverage: Indicate if any persons on the application have other group coverage or individual insurance.
- 7. Medicare Section: Complete if you, your spouse, or dependent child(ren) have Medicare coverage.
- 8. Prior Coverage for PPO Plans Only: Provide information to receive proper credit for previous coverage if applicable.
What happens if I fail to submit this form?
Failure to submit the Anthem Blue Cross Enrollment Form can result in no coverage for you and your dependents.
- No Medical Coverage: You and your dependents will not be enrolled in the medical plan.
- No Dental Coverage: You and your dependents will not have dental insurance.
- No Vision Coverage: You and your dependents will not have vision insurance.
- Missed COBRA Enrollment: Failure to enroll in COBRA/Cal-COBRA can result in loss of extended insurance coverage.
How do I know when to use this form?
- 1. New Enrollment: For employees enrolling in health coverage for the first time.
- 2. Changing Coverage: For employees updating their existing coverage details.
- 3. Adding Family Members: For including eligible family members in your coverage.
- 4. COBRA Enrollment: For continuing health coverage through COBRA/Cal-COBRA.
- 5. Declining Coverage: For employees choosing to decline certain coverages.
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Navigate to the declination section, check the appropriate boxes, and provide the necessary information.
How can I ensure my family members are correctly added?
List all eligible family members in the Employee and Family Information section and review for completeness.
Can I use PrintFriendly to fill out the COBRA/Cal-COBRA section?
Yes, complete the COBRA/Cal-COBRA section by providing the required dates and information as outlined in the form.
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