Application for an Individual Health Contract for Aware Care or Options Blue
BlueCross® BlueShield®
of Minnesota
An Independent Licensee of the Blue Cross and Blue Shield Association

P.O. Box 64024, St. Paul, MN 55164
FOR COMPANY USE ONLY
 
Y O          
 Effective Date 
           
 
FOR AGENT USE ONLY (Please print legibly)
  Agency code
B  
P
P
 
 Agent
  Agent's number
5
5
0
1
 name ____________________________
 
1.
Applicant's name
LAST
FIRST
MIDDLE
2.
Applicant's
social security number
 - -  
Spouse's
social security number
 - -
3.
Sex
Male
Female
  
4. Marital status
Single
Married
Widowed
Divorced
Separated
5.
Applicant's address
 
STREET
CITY
STATE
ZIP
6.
Are you a permanent resident of Minnesota currently residing in Minnesota?
Yes
No
  
If no, please explain.
7.
Payment mode (check one):
Annual
(12 months)
Semiannual
(6 months)
Quarterly
(3 months)
Pay-O-Matic
(1 month)
Amount paid with this application $ Please make your check payable to Blue Cross and Blue Shield of Minnesota (BCBSM). We do not accept business checks for payment of coverage (see exception on page 4).
8.
Applicant's occupation and employer (or employment status)
9. Spouse's occupation and employer (or employment status)
10.
Starting with yourself, list each family member for whom application is being made.
 
Full name and Social Security #
Relationship
to applicant
Birth date
mo/day/yr
Height
Present
weight
Weight one
year ago
Name
 (Applicant)
/ /
ft. in.
lbs.
lbs.
Name

/ /
ft. in.
lbs.
lbs.
Name

/ /
ft. in.
lbs.
lbs.
Name

/ /
ft. in.
lbs.
lbs.
Name

/ /
ft. in.
lbs.
lbs.
 
For any dependents age 19-24 listed in item 10, complete the following:
 
Name of dependent
Full-time
Student
Anticipated
graduation date
School name
Yes No /
Yes No /
11.
Aware Care ONLY, select your choice of deductible:
I apply for the following calendar-year deductible:
$300   $500   $750   $1,000   $1,500   $2,000   $3,000   $5,000   $10,000
If applying for a $5,000 deductible, select benefit percentage 80%   100%
12.
Options Blue ONLY, select your choice of plan, deductible and preventive care:
Options Blue 80:
Low deductible
Middle deductible
High deductible
       Preventive Option:
100% to a maximum of $300, then 80% after deductible
80% after deductible
Options Blue 100:
Low deductible
Middle deductible
High deductible
       Preventive Option:
100% to a maximum of $300, then 100% after deductible
100% after deductible
The deductible and out-of-pocket maximum benefits are subject to annual adjustments on the annual renewal date. These adjustments are based on the Consumer Price Index (CPI) published by the Federal Department of Labor.
 
F2266ER21 (08/04)         Page 1 of 4  
13.
PREVIOUS HEALTH INSURANCE INFORMATION
Do you or any family member included on this application currently have any health insurance or had any health
insurance within the past 63 days?...................................................................................................................................
Yes
No
If YES, you must fully complete the following section by providing all health insurance information
for the past 12 months for you and any family member included on this application:
Person
Covered
Insurance Company
Company name and policy number
Date Coverage
Started
Date Coverage
Ended
Reason for
termination of
health care coverage
Was previous
coverage individual
or group
coverage?
/ / / /
/ / / /
/ / / /
/ / / /
14.
REASON FOR APPLICATION (complete one):
I am a new applicant presently not covered under a BCBSM contract.
  
I presently have BCBSM coverage. I am covered under I.D. number
I presently have BCBSM individual coverage and want to add my dependent(s)
 
listed on the previous page. My contract identification (ID) number is
15. 
TOBACCO USE DESIGNATION AND DECLARATION:
 Yes No
 
A. I have used tobacco and/or smokeless tobacco during the 24 months immediately preceding the date
 
of this application..................
  B. My spouse (if included on this application) has used tobacco and/or smokeless tobacco during the 24 months immediately  
  preceding the date of this application......................................................................................................................
  NOTE:Tobacco-free rates are available only to persons who have not used tobacco and/or smokeless tobacco in the preceding 24 months.
16.  CHEMICAL DEPENDENCY COVERAGE:
  Coverage for chemical dependency is included in the contract. You may choose to delete chemical dependency coverage. Your premium will be slightly reduced if you delete chemical dependency coverage. Your decision to retain or delete chemical dependency coverage applies to all individuals applying for coverage under this contract.
Check this box if you want to EXCLUDE chemical dependency coverage....................................................................		  
17. 
HEALTH HISTORY (Complete information is required for all family members who are applying for coverage.)
  
 
Have you or any other family member listed in this application ever had, been treated for or diagnosed as having diseases or disorders related to the following conditions? (Check each item either "Yes" or "No" and select conditions.)
  
  You do not have to disclose tests to detect the presence of human immune deficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV), or other bloodborne pathogens which were administered to you at the time you were: (1) a criminal offender or crime victim as a result of a crime that was reported to the police; (2) an emergency medical personnel who was tested as a result of performing emergency medical services while employed; (3) corrections employees or inmates; or (4) patients or employees of a secured facility. The term emergency medical personnel includes individuals employed to provide out of hospital medical emergency services, licensed police officers, firefighters, paramedics, emergency medical technicians, licensed nurses, rescue squad personnel, or other individuals who serve as employees or volunteers of an ambulance service who provide emergency medical services; a member of an organized first responder squad that is formally recognized by a political subdivision in Minnesota; crime lab personnel; other persons who render emergency care or assistance at the scene of an emergency, or while an injured person is being transported to receive medical care and who would qualify for immunity under the good samaritan law; and any individual who, in the process of executing a citizen's arrest, may have experienced a significant exposure. Yes No
 
A.
HEART OR CIRCULATORY DISORDERS-- Chestpain, rheumatic fever, heart murmur, stroke,
high blood pressure, anemia, bleeding disorders, varcisose veins, myocardial infarction, or heart disease
 
B.
GASTROINTESTINAL DISORDERS-- Stomach, gallbladder, liver, intestinal bleeding or disorders, ulcers, hernia, hemorrhoids, chronic diarrhea, or rectal disorders.................................................................
 
C.
GENITOURINARY DISORDERS-- Kidney, urinary tract disorders, sexually transmitted diseases, infertility, disorders of the male reproductive system including the prostate gland,
disorders of the female reproductive system including menstrual disorders and abnormal pap smears.........................
 
D.
BREAST DISORDERS-- Disorders of the male or female breast, including complications from breast implants........
 
E.
RESPIRATORY DISORDERS-- Asthma, emphysema, bronchitis, allergy or allergic reaction, lung, or breathing disorder...................................................................................................................................................................
 
F.
NERVOUS, EMOTIONAL, MENTAL OR PERSONALITY DISORDERS-- Depression, anxiety, adjustment disorders, eating disorders, attention deficit disorders, hyperactivity, behavioral, or
psychotic disorders.................................................................................................................................................................
 
G.
ENDOCRINE OR GLANDULAR DISORDERS-- Diabetes, thyroid, adrenal, pituitary,
pancreas, or lymph node/gland enlargement....................................................................................................................
 
H.
NEUROLOGICAL OR NEUROMUSCULAR DISORDERS-- Headache or migraine, head injury,
seizure disorder, multiple sclerosis, cerebral palsy, paralysis, or chronic fatigue syndrome............................
 
I.
MUSCULOSKELETAL DISORDERS-- Back disorders, scoliosis, temporomandibular joint disorder (TMJ), fibrositis, fibromyalgia, carpal tunnel syndrome, gout, arthritis, joint disorders, or amputation.......
 
J.
CANCER, SARCOMA, TUMOR, CYST, OR POLYP..................................................................................
 
K.