HTML Preview Dental Employee Application Form page number 1.
PLEASE PROVIDE THE FOLLOWING:
NEW APPLICATION
RE-HIRE
ADD FAMILY MEMBER TO EXIST-
ING COVERAGE
APPLICANT’S SOCIAL SECURITY NUMBER
_____ _____ _____ - _____ _____ - _____ _____ _____ _____
FIRST NAME
MI LAST NAME
DATE OF HIRE GROUP NAME BIRTHDATE
REQUESTED EFFECTIVE DATE ______/_____/_____
CHOOSE DENTAL PLAN (CHECK ONE BOX ONLY):
DENTAL PPO DENTAL HMO
IF YOU ARE APPLYING FOR THE DENTAL HMO, YOU MUST CHOOSE A DENTAL PROVIDER FROM THE BLUE SHIELD DENTAL PROVIDER
DIRECTORY (ALSO AVAILABLE ONLINE AT WWW.MYLIFEPATH.COM). THE DENTAL PROVIDER YOU CHOOSE WILL PROVIDE AND ARRANGE
DENTAL CARE FOR YOU AND ALL COVERED DEPENDENTS.
MARRIED/DOMESTIC
PARTNER
Y N
E-MAIL ADDRESS APPLICANT’S BUSINESS PHONE NUMBER
( )
APPLICANT’S HOME PHONE
( )
RESIDENCE OF APPLICANT
CITY STATE ZIP CODE
MAILING ADDRESS (IF DIFFERENT FROM ABOVE)
CITY STATE ZIP CODE
LIST APPLICANT AND ALL FAMILY MEMBERS YOU WISH TO COVER. (DEPENDENT CHILDREN MUST BE UNDER AGE 19, OR UNDER AGE 23 IF FULL-TIME STUDENTS.)
FOR DENTAL HMO: YOU MUST SELECT A DENTAL PROVIDER FROM THE DENTAL HMO PROVIDER CENTER DIRECTORY. (ALSO AVAILABLE ONLINE AT WWW.MYLIFEPATH.COM).
BE SURE TO INCLUDE THE DENTAL PROVIDER NUMBER LISTED. (IF YOU HAVE ANY QUESTIONS REGARDING YOUR DENTAL PROVIDER SELECTION, CALL (800) 585-8111).
1
MALE
FEMALE
YOUR FIRST NAME MI LAST (IF DIFFERENT FROM ABOVE)
DENTAL HMO ONLY: DENTAL PROVIDER NUMBER DENTAL HMO ONLY: DENTAL PROVIDER NAME
2
HUSBAND
WIFE
DOMESTIC
PARTNER
FIRST NAME MI LAST (IF DIFFERENT FROM ABOVE) DATE OF BIRTH (MO/DAY/YR)
_____/_____/___________
SPOUSE’S/DOMESTIC PARTNER'S
SOCIAL SECURITY NUMBER
___ ___ ___ - ___ ___ - ___ ___ ___ ___
DENTAL HMO ONLY: DENTAL PROVIDER NUMBER DENTAL HMO ONLY: DENTAL PROVIDER NAME
3
SON
DAUGHTER
FIRST NAME MI LAST (IF DIFFERENT FROM ABOVE) DATE OF BIRTH (MO/DAY/YR)
_____/_____/___________
DEPENDENT SOCIAL SECURITY NUMBER
___ ___ ___ - ___ ___ - ___ ___ ___ ___
DENTAL HMO ONLY: DENTAL PROVIDER NUMBER DENTAL HMO ONLY: DENTAL PROVIDER NAME
4
SON
DAUGHTER
FIRST NAME MI LAST (IF DIFFERENT FROM ABOVE) DATE OF BIRTH (MO/DAY/YR)
_____/_____/___________
DEPENDENT SOCIAL SECURITY NUMBER
___ ___ ___ - ___ ___ - ___ ___ ___ ___
DENTAL HMO ONLY: DENTAL PROVIDER NUMBER DENTAL HMO ONLY: DENTAL PROVIDER NAME
5
SON
DAUGHTER
FIRST NAME MI LAST (IF DIFFERENT FROM ABOVE) DATE OF BIRTH (MO/DAY/YR)
_____/_____/___________
DEPENDENT SOCIAL SECURITY NUMBER
___ ___ ___ - ___ ___ - ___ ___ ___ ___
DENTAL HMO ONLY: DENTAL PROVIDER NUMBER DENTAL HMO ONLY: DENTAL PROVIDER NAME
6
CERTIFICATION FOR STUDENTS AGE 19-24 . I CERTIFY THAT MY DEPENDENT LISTED BELOW IS CURRENTLY ENROLLED AS A FULL-TIME STUDENT. IF YOU HAVE MORE THAN ONE DEPENDENT
OVER AGE 18 WHO IS A FULL-TIME STUDENT, PLEASE ATTACH ANY ADDITIONAL SHEET WITH THE REQUIRED INFORMATION AND CHECK HERE.
NAME HOURS/WEEK UNITS SCHOOL ADDRESS
Dental Only
EMPLOYEE APPLICATION
(No Medical)
DO NOT WRITE IN SHADED AREAS
DISCLOSURE STATEMENTS – Please read these conditions of membership and authorization and sign below.
1. To find Blue Shield dental provider by name, location and specialty, go to our Web site: www.mylifepath.com. You can use the Web site to print out a listing of Blue
Shield providers in your area. This directory is for information purposes only and is not to be considered a total representation of Blue Shield’s Dental Provider Network.
2. Parent or Legal Guardian (if the applicant is a minor): I will assume all responsibility for dues payments and for managing the provision of benefits under the plan
applied for by my child. Individuals authorized to make changes to my minor child’s contract include
A. Parent or Legal Guardian only or,
B. my designee ________________________________________________ (include relationship) or,
C. Qualified Medical Child Support Order designee ________________________________________________ (include relationship).
I further request that all changes to this contract be made only upon Blue Shield’s receipt of such written request.
Please indicate only one: A B or C. (Court documents must be attached authorizing guardianship if the responsible adult is not the parent.)
C15366 (11/05)
SHADED BOX – FOR BSC ONLY
GROUP NUMBER _____________________________________
PLAN TYPE _____________________________________
EFFECTIVE DATE _____________________________________