BCBSM Enrollment/Change of Status Form

1 SUBSCRIBER INFORMATION - COMPLETE SECTION 1 THROUGH 4. Social Security Number/ Contract Number Subscriber Last Name check if new Subscriber First Name MI. SECTION 1. Home Street Address check if new City State Area Code/Home Phone Information Instructions enrollment / Zip Code County Current Marital Status Area Code/Work Phone CHANGE OF Status Single Married List all persons to be enrolled / terminated: M. S. DATE OF BIRTH *R OC PRIMARY CARE PHYSICIAN NAME - BCN/POS ONLY Seen in the E SOCIAL SECURITY # last Circle LAST NAME FIRST NAME I MMDDYY E D LAST NAME FIRST PHYSICIAN # PHYSICIAN LOCATION 12 months One X L E INITIAL YES NO. Subscriber Add M. Delete F. Spouse Add M. Delete F. Add M. Dep-1. Delete F. Add M. Dep-2. SUBSCRIBER. Delete F. SECTION 2.

2 Add M. Dep-3. Delete F. * Relationship Code Previous BCBSM /POS Affiliation PCP Change Reason - BCN/POS ONLY. N - Child (by Birth or Adoption) P - Principal Support* SD - Sponsored Dependent* I have previously been enrolled in : S - Stepchild A - Child Adoption in Process** C - Court Order Coverage (QMCSO)** (Check applicable box). F - Family Continuation 19+ L - Legal Guardianship** D - Disabled Child (PA 275)** BCBSM BCN POS. * = Attach Documentation ** = Attach Court Order ** = Attach Physician Statement Enter contract #. If the permanent address of the spouse or dependent is different from address in section one, please complete information below: Spouse/Dependent (Full name) Street Address City State Zip code Do you, your spouse or dependent(s) maintain other health coverage?

3 NO YES If Yes, complete below: SECTION 3. OTHER COVERAGE. Person covered (Full name) Group Policy Number Carrier Location Person covered (Full name) Group Policy Number Carrier Location Are you, your spouse or any dependents listed in section 2 enrolled in Medicare ? No Yes If Yes, attach a copy of Medicare card(s). Actively working Retired Under 65 ESRD (End Stage Renal Disease). SIGNATURE. I have read and understand the conditions on page 1 of this form. SEC. 4. Subscriber Signature Signature Date Remarks GROUP USE ONLY- CHECK AND COMPLETE APPROPRIATE BOXES. BCBSM Group/Suffix or BCN Group Subgroup BCBSM Service Code/BCN Class Employee Badge # Group Name Group Representative Signature Date COVERAGE/PLAN: Blue Care Network Plan: Medical Rx Hearing Vision Dental BCBSM Coverage: Traditional/CMM POS PPO Dental Only Vision Only Effective Date: Date of Hire or Full Time Part-Time Open enrollment Return to work from Layoff New Hourly Retiree GROUP USE ONLY.

4 Status : enrollment : Rehire Full-Time Salary Surviving Spouse HIPAA Qualifying Event (describe event): SECTION 5. Effective Date: Marriage Duplicate ID Card Name Change Address Change REASON FOR Loss of Coverage (Certificate of Creditable Coverage Required). CHANGE: Dependent(s) PCP Change FCR/DCCR Transfer HIPAA Qualifying Event (describe event): Last Date of Coverage: Contract REASON: COBRA Dependent Over Age Left Employment CANCEL. COVERAGE: Spouse Divorce Death Other Dependent(s) list in Section 2 Retired Other Insurance Original Qualifying Date: COBRA Termination Layoff Divorce/Legal Separation enrollment : Reduction of Hours Deceased Subscriber Loss of Dependent Status Previous Contract #. Effective Date: MEDICARE Status : Medicare Primary per MSP Law(s) BCBSM /BCN Primary per MSP Law(s) Please attach a copy of Medicare card(s).

5 WF 3599 MAY 05 Page 3 of 3 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. k