BluePreferred - Miscellaneous Forms - Maryland

Miscellaneous Forms - Maryland

FormEXCLUDING PG & Montgomery CountiesONLY PG & Montgomery Counties
Contract and Benefits Booklet Request Form CUT6592 CUT6592
Full-Time Equivalent (FTE) Group Size Calculation Worksheet FRM6237 FRM6237
Medicare Secondary Payer (MSP) Calculation Form FRM4011 FRM4011
Enrollment Transaction Report (ETR) CUT5796 CUT5795
Waiver of Enrollment CUT6529 CUT6529
Confirmation of Enrollment CUT5802 CUT5801
Disability Certification for Overaged Dependent CUT5625 CUT5625
Primary Caretaker Certification N/A N/A
COBRA Continuation CUT5870 CUT5861
Selection Form for Continuation of Group Coverage CUT5862 CUT5872
Group Screening Questionnaire (51+ Groups) CUT6668 CUT5486
Proof of Prior Group Dental Coverage for Voluntary Dental SUM1750 SUM1750
Affiliated Companies/Common Ownership Certification CUT9069 CUT9069
Maryland Stop Loss Application (Self-Funded Underlying Medical Product) MD/CFMI/SL APP (R. 7/15) MD/GHMSI/SL APP (R. 7/15)
Maryland Stop Loss Disclosure MD/CFMI/SL APP (7/15) MD/GHMSI/SL APP (7/15)