BlueChoice HMO and BlueChoice HMO Open Access - Miscellaneous Forms - District of Columbia

Miscellaneous Forms - District of Columbia

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) CUT5486
Affiliated Companies/Common Ownership Certification CUT9069
Proof of Prior Group Dental Coverage for Voluntary Dental SUM1750
D.C. Risk Groups Employer Request for Religious Accommodations SUM5049