Issued By:
Capital BlueCross
Capital Advantage Assurance Company ®
Capital Advantage Insurance Company®
Keystone Health Plan® Central
Independent Licensees of the BlueCross BlueShield Association
Application for Coverage
Who can use this application?
• You can use this application for anyone who needs health insurance or dental insurance.
• Apply faster online at capbluecross.com
What happens next?
• If you apply by paper, send your complete, signed application and premium payment information to:
Capital BlueCross
PO Box 772612
Harrisburg, PA 17177-2612
OR
Fax to: 717.541.6667
Email to: [email protected]
• Your application will be processed and you will receive your enrollment materials.
Get help with this application.
• Phone: Call our Sales department at 1.800.451.1181
• In Person: V
isit our Retail Store located at:
2845 Center Valley Parkway,
Suite 404/409, Center Valley, PA 18034
Information is private.
• We’ll keep your information private as required by law.
HMO medical issued by Keystone Health Plan Central
PPO medical issued by Capital BlueCross and Capital Advantage Insurance Company
PPO medical issued by Capital Advantage Assurance Company
Dental issued by Capital Advantage Assurance Company
Vision issued by Capital Advantage Assurance Company
Drug issued by Capital Advantage Assurance Company
NEED HELP WITH YOUR APPLICATION? Call us at 1.800.451.1181, or visit us at capbluecross.com.
Para obtener una copia de este formulario en Español, llame 1.800.451.1181.
Ind-APP-v0114
Page 1 of 10
C-423 (10/2013)
Applicant Details
Tell us about yourself.
Effective Date:
Request type:
 New application
 Add dependent
 New application – Child Only Policy
 Remove dependent
 Dental application (if dental only, please skip
medical selection section on pages 5 and 6)
Subscriber I.D. #:
Special enrollment reason:
Subscriber
First Name
Middle Initial
Last Name
Home Address
Title
Address Line 2
City
State
Zip Code
County
Address Line 2
Mailing Address (if different from home address)
City
State
Zip Code
Phone Number
Other Phone Number
()–
()–
County
I would like to get information about this application by:
Email: Yes
 No
Email Address:
Text:  Yes
 No
Cell Phone Number: ()–
Preferred Language Spoken (if not English)
Preferred Language Read (if not English)
Social Security Number
Gender:
–
Tobacco User:  Yes
 Male
–
Date of Birth (MM/DD/YYYY)
 Female
/
/
 No
(Tobacco use is considered to be four or more times per week, and should be answered only if the individual is 18 years or older.)
If yes, date tobacco was last used (MM/DD/YYYY)
/
/
Now, tell us who else needs insurance.
Ind-APP-v0114
Page 2 of 10
C-423 (10/2013)
Dependents
Tell us about anyone who needs insurance.
Attach additional sheets of paper if you need to.
Step 2: Spouse
First Name
Middle Initial
Last Name
Gender:
Social Security Number
–
 Male
–
Suffix
Date of Birth (MM/DD/YYYY)
 Female
/
/
Does this person live at the same address as you?
 Yes
 No
If no, list address:
Relationship to you?
Tobacco User:  Yes
 No
(Tobacco use is considered to be four or more times per week, and should be answered only if the individual is 18 years or older.)
If yes, date tobacco was last used (MM/DD/YYYY)
/
/
Step 2: Dependent 1
First Name
Middle Initial
Last Name
Gender:
Social Security Number
–
 Male
–
Suffix
Date of Birth (MM/DD/YYYY)
 Female
/
/
Does this person live at the same address as you?
 Yes
 No
If no, list address:
Relationship to you?
Handicap Dependent:  Yes
 No
Certification will be required.
Tobacco User:  Yes
 No
(Tobacco use is considered to be four or more times per week, and should be answered only if the individual is 18 years or older.)
If yes, date tobacco was last used (MM/DD/YYYY)
Ind-APP-v0114
/
Page 3 of 10
/
C-423 (10/2013)
Dependents
(continued)
Step 2: Dependent 2
First Name
Middle Initial
Last Name
Gender:
Social Security Number
–
 Male
–
Suffix
Date of Birth (MM/DD/YYYY)
 Female
/
/
Does this person live at the same address as you?
 Yes
 No
If no, list address:
Relationship to you?
Handicap Dependent:  Yes
 No
Certification will be required.
Tobacco User:  Yes
 No
(Tobacco use is considered to be four or more times per week, and should be answered only if the individual is 18 years or older.)
If yes, date tobacco was last used (MM/DD/YYYY)
/
/
Step 2: Dependent 3
First Name
Middle Initial
Last Name
Gender:
Social Security Number
–
 Male
–
Suffix
Date of Birth (MM/DD/YYYY)
 Female
/
/
Does this person live at the same address as you?
 Yes
 No
If no, list address:
Relationship to you?
Handicap Dependent:  Yes
 No
Certification will be required.
Tobacco User:  Yes
 No
(Tobacco use is considered to be four or more times per week, and should be answered only if the individual is 18 years or older.)
If yes, date tobacco was last used (MM/DD/YYYY)
Ind-APP-v0114
/
Page 4 of 10
/
C-423 (10/2013)
Product Selection
Select Medical Product
Drug benefits and pediatric vision benefits are always included with your medical plan selection.
Medical, Drug, Pediatric Vision, and Pediatric Dental Products
Catastrophic Option
Bronze Options
Silver Options
Gold Options
N/A
N/A
Healthy Benefits PPO
0/0 50 PD
PPOIJ219 ❏
Healthy Benefits PPO
1000/0 PD
PPOIJ221 ❏
Medical, Drug, and Pediatric Vision Products
The following products do not include pediatric dental coverage. To purchase these products, you must have
purchased an exchange-certified stand-alone pediatric dental plan. Please provide the name of the company that
is providing this coverage, together with the name of the plan.
Name of Company:
Name of Plan:
I hereby certify that I have and will continue to maintain the exchange-certified stand-alone pediatric dental plan
indicated above for as long as I maintain enrollment in the product selected below.
Catastrophic Option
Bronze Options
Silver Options
Gold Options
Healthy Benefits HMO
6350/0
HMOIJ356 ❏
Healthy Benefits PPO
HSA 4000/50
PPQIJ200 ❏
Healthy Benefits PPO
6000/0
PPOIJ207 ❏
Healthy Benefits PPO
500/0
PPOIJ209 ❏
Healthy Benefits PPO
0/0 10
PPOIJ212 ❏
N/A
Healthy Benefits PPO
HSA 6000/0
PPQIJ202 ❏
N/A
Healthy Benefits PPO
3000/0
PPOIJ206 ❏
N/A
N/A
N/A
N/A
Healthy Benefits PPO
0/0 25
PPOIJ211 ❏
N/A
Does the product selection you chose apply to all of the persons you identified in Steps 1 and 2?
 Yes
 No
If no, please specify the product selection for each family member:
Primary Applicant:
Product Selection:
Spouse:
Product Selection:
Dependent 1:
Product Selection:
Dependent 2:
Product Selection:
Dependent 3:
Product Selection:
Ind-APP-v0114
Page 5 of 10
C-423 (10/2013)
Product Selection
(continued)
Primary Care Physician
If you or a covered person selected a medical HMO product, you are required to select a Primary Care Physician.
You and each dependent can select his/her own Primary Care Physician from the Keystone Health Plan Central
Provider Directory or on our website capbluecross.com. The directory or website may indicate that the physician
you wish to select is available to current patients only. If you are currently a patient of that physician, please
indicate that in this section of the application. If you are not currently a patient, you must select a different Primary
Care Physician.
Applicant’s Primary Care Physician Selection
Practice’s Name
Primary Care Physician Code # Current Patient
 Yes
 No
Spouse’s Primary Care Physician Selection
Practice’s Name
Primary Care Physician Code # Current Patient
 Yes
 No
Dependent 1’s Primary Care Physician Selection
Practice’s Name
Primary Care Physician Code # Current Patient
 Yes
 No
Dependent 2’s Primary Care Physician Selection
Practice’s Name
Primary Care Physician Code # Current Patient
 Yes
 No
Dependent 3’s Primary Care Physician Selection
Practice’s Name
Primary Care Physician Code # Current Patient
 Yes
Ind-APP-v0114
Page 6 of 10
 No
C-423 (10/2013)
Product Selection
(continued)
Select Dental Product
We offer pediatric only dental products* and dental products that cover adults and pediatrics.
Healthy Dental PPO Pediatric*
BPDI0107 ❏
Healthy Dental PPO Plan 2
BCDI0104 ❏
Healthy Dental PPO Plan 1
BCDI0103 ❏
Healthy Dental PPO Plan 3
BCDI0105 ❏
Healthy Dental HMO Pediatric
702xs*
BPDI0109 ❏
Healthy Dental HMO Basic
BCDI0107 ❏
* Only available for eligible individuals under the age of 19.
Does the dental product selection you chose apply to all of the persons you identified in Steps 1 and 2?
 Yes
 No
Note: If you selected a medical plan that includes pediatric dental coverage and you also select a standalone dental plan for your
dependent(s) under the age of 19, coverage in the medical plan is primary over the standalone dental policy.
If no, please specify the dental product selection for each family member:
Primary Applicant:
Product Selection:
Spouse:
Product Selection:
Dependent 1:
Product Selection:
Dependent 2:
Product Selection:
Dependent 3:
Product Selection:
Ind-APP-v0114
Page 7 of 10
C-423 (10/2013)
Premium Payment
Payment of your first month’s premium is due at time of application; please select a
payment method below:
Billing Method (please select one):
 Please send me a bill.
 Bill Payer (please complete additional information below)
 Credit Card (If paying by credit card, please go to capbluecross.com/wps/wcm/connect/cbc-public/cbc/paymypremium/paymypremiumhome
to authorize payment.
 Please enroll me in Check It Out ® automatic withdraw program. (please complete additional information below)
Financial Institution Information (please print)
Name of Financial Institution
ABA Number
Name of Bank Account
Bank Account Number
Signature of Capital BlueCross Subscriber
Account Type for Withdrawal
 Checking
Signature (if joint account)
Date
 Savings
Signature (if account is other than subscriber’s)
Date
Please note: Notification of premium changes will be
sent to the subscriber only.
Bottom of Check
ABA/Transit Routing Number
Account Number
Please complete the following information if using Bill Payer
Name on Account
Financial Institution’s Name
Name of Insured
Date Payment will be Transfered
Financial Institution’s Confirmation Number
Producer of Record
If you worked with a licensed sales agent who is appointed with Capital BlueCross or its family of companies, please
have the producer complete the following section. If you worked independently, please leave this section blank.
Producer (please print)
Signature of Producer
Name (Producer)
Producer ID #
Name (General Agent)
Producer’s Email
Ind-APP-v0114
Page 8 of 10
Signature of Producer
Date
C-423 (10/2013)
Notification and Authorization
Please note: If you and your spouse are applying for coverage, your spouse is considered a coapplicant and also must
read and accept these “conditions of enrollment,” and sign and date this application for coverage below. In addition, any
dependents age 18 or older for which coverage is requested must also read and accept these “conditions of enrollment,” and
sign and date this application for coverage below.
I hereby apply for the coverage indicated. I understand this application is subject to approval by Capital BlueCross. Any
coverage will be subject to the terms of the contract issued to me.
You must have your primary residence in the Capital BlueCross 21-county service area, which includes Adams, Berks, Centre,
Columbia, Cumberland, Dauphin, Franklin, Fulton, Juniata, Lancaster, Lebanon, Lehigh, Mifflin, Montour, Northampton,
Northumberland, Perry, Schuylkill, Snyder, Union, and York counties.
Your enrollment application must be received by Capital BlueCross during the initial or annual open enrollment periods. If you
qualify for a special enrollment period, your application must be received during your special enrollment period.
If changes are indicated, Capital BlueCross is authorized to make the changes requested above to my enrollment records. I
understand the effective date of the changes will be determined by Capital BlueCross.
I/we verify that the information given in this enrollment application is true and correct. Any person who knowingly and with
intent to defraud any insurance company or other person, files an application for insurance or statement of claim contacting
any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto,
commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
Applicant’s Signature:
Printed Name:
Date:
/
/
Date:
/
/
Date:
/
/
Date:
/
/
Date:
/
/
Coapplicant’s/Spouse’s Signature:
Printed Name:
Dependent’s Signature (if age 18 or older):
Printed Name:
Dependent’s Signature (if age 18 or older):
Printed Name:
Dependent’s Signature (if age 18 or older):
Printed Name:
Representative ID (to be completed if requested by your representative)
If you applied for a Child Only Policy, please complete this section:
Name of Guarantor: First Name
Middle Initial
Last Name
Guarantor’s Home Address
Title
Address Line 2
City
State
Phone Number
Relationship to Child
Ind-APP-v0114
Page 9 of 10
Zip Code
County
C-423-A (10/2013)
Replacement of Coverage
Replacement of Inforce Policy
Is the insurance being applied for intended to replace any other accident and health insurance currently in force?
 Yes  No
If you answered yes to the previous question, please complete the following information:
Notice to Applicant Regarding Replacement
If you intend to lapse or otherwise terminate existing health insurance coverage and replace it with coverage to
be issued by Capital BlueCross, Capital Advantage Insurance Company, Capital Advantage Assurance Company,
and Keystone Health Plan Central (Capital), please be advised of the following. Your new contract with Capital will
provide a period of 10 days after receipt of the contract within which you may decide whether you desire to keep
the contract. For your own information and protection, you should be aware of and seriously consider certain
factors which may affect the insurance protection available to you under the new contract.
1.Health conditions which you may presently have (preexisting conditions) will be covered under the new contract
as long as the treatment for which you seek coverage is a covered benefit.
2.There are no waiting periods under your new contract for coverage to be effective.
3.You may wish to secure the advice of your present insurer or its agent regarding the proposed replacement of
your present coverage. This is not only your right, but is also in your best interest to make sure you understand
all of the relevant factors involved in replacing your present coverage.
4.If, after due consideration, you still wish to terminate your present coverage and replace it with new coverage,
be certain to truthfully and completely answer all questions on the application. Failure to include all material
medical information on your application may provide a basis for the company to deny or terminate coverage
and to refund your premium as though your contract had never been in force.
The above Notice to Applicant was delivered to me and read on: Date:
Applicant Name (please print):
Applicant Signature:
Coapplicant Name (please print):
Coapplicant Signature:
Ind-APP-v0114
Page 10 of 10
C-423-B (10/2013)