HealthyBlue - Miscellaneous Forms - Maryland

Miscellaneous Forms - Maryland

FormMaryland (EXCLUDING PG & Montgomery Counties)Maryland (ONLY 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
BlueChoice Point of Service Selection N/A N/A
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. 1/13) MD/GHMSI/SL APP (R. 9/13)