Membership Change Form - CareFirst

1 CareFirst of Maryland, Inc. 10455 Mill Run Circle, Owings Mills, MD 21117 Group Hospitalization and Medical Services, Inc. CareFirst BlueChoice, Inc. 840 First Street, NE, Washington, DC 20065 This is not an application for insuranceMembership Change FormACA Maryland Individual PlansMailroom Administrator Box 14651, Lexington, KY 40512 Fax: 410-505-2901 or toll free 800-305-1351If you purchased your insurance directly through the Maryland Health Connection, DC Health Link, or Virginia Health Insurance Marketplace, then you MUST contact them directly to make changes to your policy. Subscriber s Last NameFirst of Birth (mm/dd/xxxx) / /Residence Address (Street)(City and State)Zip CodeResidence CountySubscriber ID# (SID)Group #SSNP hone Number( )CHANGES REQUESTED (please check box of requested Change )ADDRESS*Residence AddressStreetCityCountyStateZip CodeBilling AddressStreetCityCountyStateZip CodeRequested Effective Date of Change (mm/dd/xxxx) / /* If moving out of state please contact Sales at 800-544-8703 or your NUMBERHomeOld Phone Number( )New Phone Number( )Work/CellOld Phone Number( )New Phone Number( )NAME (legal documentation required) Change Change Reason.

2 Marriage Divorce Other:REMOVE A DEPENDENTDue to:Divorce Date of Divorce: / / Death (death certificate required) Date of Death: / / Extended Military Other: Dependent Information (Please list all persons to be removed) of Birth / / of Birth / / of Birth / / SSNCareFirst 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 both independent licensees of the Blue Cross and Blue Shield Association.

3 Registered trademark of the Blue Cross and Blue Shield Association. Registered trademark of CareFirst of Maryland, (12/15)2 ADD/ Change PRIMARY CARE PROVIDER (PCP) INFORMATIONPCP for to:PCP#Existing Patient? Yes NoPCP for to:PCP#Existing Patient? Yes NoPCP for to:PCP#Existing Patient? Yes NoCHANGE Membership (due to death of Subscriber*) dependent to his/her own policyDependent Information Set up for continuous coverage LastFirstMIType of Current CoverageSSNLastFirstMIType of Current CoverageSSN*Documentation from: Individual and Child(ren) Individual and Adult Family Change to: Individual Individual and Child(ren) Membership (Subscriber moving to Medigap) dependent to his/her own policyMoving Member: Please attach this form to the completed MediGap Information Set up for continuous coverage LastFirstMIType of Current CoverageSSNLastFirstMIType of Current CoverageSSNR emaining members will be enrolled into their own policy with the same plan and no break in from.

4 Individual and Child(ren) Individual and Adult Family Change to: Individual Individual and Child(ren) OTHER HEALTH INSURANCE INFORMATION Is any person listed on the Change form covered by another health care plan or HMO? Yes NoIf yes, will this coverage be continued? Yes No If No, please provide the cancellation date: / /Policyholder s Name: of Insurance Company:Phone Number of Other InsurerAddress of Insurance Company: StreetCityStateZipPolicy NumberGroup NumberEffective Date of Policy / /Name of Employer Providing Coverage (if applicable)Does this policy cover: You? Yes No Your Spouse/Partner? Yes No Your children? Yes NoPlease list the name(s) of child(ren) covered:Policyholder s working status: Active Retired Retirement date.

5 / /IF YOU HAVE OTHER HEALTH INSURANCE COVERAGE, FAILURE TO COMPLETE THIS SECTION WILL CAUSE SIGNIFICANT DELAYS IN PROCESSING ANY CLAIMS (12/15)3 ELECTRONIC COMMUNICATION CONSENTCareFirst wants to help you manage your health care information and protect the environment by offering you the option of electronic of paper delivery, you can receive electronic notices about your CareFirst health care coverage through email and/or text messaging by providing your email address and/or cell phone number and consent notices regarding your CareFirst health care coverage include, but are not limited to: Explanation of Benefits Alerts Reminders Notice of HIPAA Privacy Practices Certification of Creditable CoverageYou may also receive information on programs related to your existing products and services along with new products and services that may be of interest to note: This consent for electronic communications applies to the Primary Applicant only.

6 Spouse/Domestic Partners and dependents 18 years of age and older can consent to electronic communications through Members can also Change email and consent information anytime by logging into or by calling the customer service phone number on your ID card. You can also request a paper copy of electronic notices at any time by calling the customer service phone number on your ID card. I understand that to access the information provided electronically through email, I must have the following: Internet access; An email account that allows me to send and receive emails; and Microsoft Explorer (or higher) or Firefox (or higher), and Adobe Acrobat Reader 4 (or higher).I understand that to receive notices through text messaging, A text messaging plan with my cell phone provider is required; and Standard text messaging rates will apply.

7 Primary Applicant NameEmail AddressCell Phone NumberAlternate Email AddressAlternate Cell Phone NumberBy checking below, I hereby agree to electronic delivery of notices, instead of paper delivery by: Email only Cell phone text messaging only Email and cell phone text messagingSignature: XCareFirst will not sell your email or phone number to any third party and we do not share it with third parties except for CareFirst business associates that perform functions on our behalf or to comply with the WARNING: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in SIGNATURE(S) AND DATES ubscriber s SignatureDate / / Member s SignatureDate / / Parent or Legal Guardian s SignatureDate / / CUT9477-1N (12/15)4 RACE, ETHNICITY, LANGUAGE (this information is voluntary)As required by Maryland law, CareFirst is asking its members to voluntarily provide their race, ethnicity and language attributes.

8 The information provided, while voluntary, will assist the State of Maryland and CareFirst of Maryland to improve quality of care and access to care thereby reducing health care disparities and promote better health outcomes. The information you provide will not have a negative impact on any services we provide you. The information is kept strictly confidential and will not be shared unless required by law to disclose EthnicityPreferred Spoken Language*White/CaucasianHispanic/Latino/ Spanish origin01 English09 Farsi18 RussianBlack or African American02 Albanian10 French (European)19 SerbianAm erican Indian or Alaska Native03 Amharic11 Greek20 SomaliAsian 04 Arabic12 Gujarati21 Spanish (Latin America)Native hawaiian or other pacific islander05 Burmese13 Hindi22 Tagalog (Filipino)06 Cantonese14 Italian23 UrduOther (To include Multi-Racial)07 Chinese (simplified & traditional)

9 15 Korean24 VietnameseDecline to answer16 Mandarin98 Other and unspecified languagesUnknown Could not be determined08 Creole (Haitian)17 Portuguese (Brazilian)99 UnknownLast NameFirst NameRaceEthnicityCountry of OriginPreferred Spoken Language (specify number from above*)Primary ApplicantSpouse/Domestic PartnerDependent 1 Dependent 2 Dependent 3 Dependent 4 Dependent 5 Dependent 6 Dependent 7 Dependent 8 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 both independent licensees of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association.

10 Registered trademark of CareFirst of Maryland, (12/15)Notice of Nondiscrimination and Availability of Language Assistance ServicesCareFirst BlueCross BlueShield, CareFirst BlueChoice, Inc. and all of their corporate affiliates ( CareFirst ) comply with applicable federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability or sex. CareFirst does not exclude people or treat them differently because of race, color, national origin, age, disability or : Provides free aid and services to people with disabilities to communicate effectively with us, such as:Qualified sign language interpretersWritten information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as.