BlueChoice Opt-Out Plus Open Access Miscellaneous Forms - District of Columbia

 

Miscellaneous Forms - District of Columbia

FormDC
Contract and Benefits Booklet Request Form CUT6592
Full-Time Equivalent (FTE) Group Size Calculation Worksheet FRM6237
Medicare Secondary Payer (MSP) Calculation Form FRM4011
BlueChoice Point of Service Selection N/A
Enrollment Transaction Report (ETR) CUT5795
Waiver of Enrollment CUT6529
Confirmation of Enrollment CUT5801
Disability Certification for Overaged Dependent CUT5625
Primary Caretaker Certification N/A
COBRA Continuation EOD5004
Selection Form for Continuation of Group Coverage EOD5001
Group Screening Questionnaire (51+ Groups) CUT9040
Affiliated Companies/Common Ownership Certification CUT9069
Proof of Prior Group Dental Coverage for Voluntary Dental SUM1750
GHMSI—DC Stop Loss Application (Self-Funded Underlying Medical Product) DC/GHMSI/SL APP (R. 9/13)