BlueCross¨ BlueShield¨
BluePlus¨
of Minnesota
Independent licensees of the Blue Cross and Blue Shield Association
 
HIPAA Notice of Special Enrollment:
If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing towards your or your dependents' other coverage). However, you must request enrollment within the time period specified by your plan (you can check a copy of your plan document) after your or your dependents' other coverage ends (or after the employer stops contributing toward the other coverage).
In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within the time period specified by your plan (you can check a copy of your plan document) after the marriage, birth, adoption, or placement for adoption.
General Notice of Pre-existing Condition Exclusion:
This plan excludes coverage for medical conditions you may have before you enroll in this plan. Unless you have continuous qualifying health coverage, you may have to wait a certain period of time for coverage for your existing health conditions. The exclusion applies to conditions for which medical advice, diagnosis, care or treatment was recommended or received within up to a six-month period before your enrollment date. This exclusion does not apply to pregnancy or to a child who is enrolled in the plan within 30 days after birth, adoption, or placement for adoption.
This exclusion may last up to 12 months (or 18 months for a late entrant) from your first day of coverage or the first day of your waiting period. A late entrant is an individual who does not enroll in the plan when first eligible to do so. The exclusion can be reduced by any days of creditable health coverage you had before enrolling if there is no gap in this coverage greater than 63 days. Your application for an individual insurance policy during a gap in coverage could reduce the gap in coverage. To reduce the exclusion period that applies to you, give us a copy of any certificate(s) of creditable coverage from a previous employer. If you do not have a certificate, but you have prior coverage, contact your former employer for a certificate. If you cannot obtain a certificate, we will help you get a certificate from your former employer or insurer. You can demonstrate creditable coverage by proving that you were covered using other documentation.
Questions on the statements above may be addressed to Blue Cross customer service at 1-888-878-0138 or (651) 662-5035.
 
F8380 (7/05)                      
 
BlueCross¨ BlueShield¨
BluePlus¨
of Minnesota
Independent licensees of the Blue Cross and Blue Shield Association
MII Life
An independent licensee of the Blue Cross
and Blue Shield Association
DELTA DENTAL¨
Delta Dental Plan of Minnesota
A. SMALL GROUP EMPLOYEE APPLICATION AND CHANGE FORM - Read instructions for Application on Page 4. Please print all information in black or blue ink.
If your employer has current group coverage with our company, provide the group and subgroup numbers:
Health

(group and subgroup)
Dental
 
Life
 
Short Term Disability
 
Long Term Disability
 
Name of Employer
 
Occupation or Duties
Full-time Employment Date
/ /
Hours working per week
Work phone
()
Home phone
()
Employee's First Name
M.I.
Last Name
Social Security Number
Date of Birth
/ /
Sex
Male Female
Height
Weight
Primary Care Clinic Number (PCC#)
(Required for Blue Plus)
Marital Status
Single Married
If married, Date of Marriage
/ /
County and State of Marriage:
/
Employee's
Home Address
Street
City
State
Zip code
B. DEPENDENT INFORMATION - List all dependents applying for coverage. Use extra paper if necessary
Name
First
M.I.
Last
Sex
Social
Security #
Relation
(Pick one)
Birth Date
(MM/DD/YYYY)
Height
Weight
PCC#
Full-time Student
(Age 19+)
M
F
Spouse