Pre-65 Enrollment Form Welcome Ohio Public Employee Retiree System 1Part I2Part II3Part III Tell Us About the Retiree (Eligible Member)Please tell us about the retiree that is being enrolled to get started.Please Choose(Required)OPF RETIREEOPF SPOUSEOPERS RETIREEOPERS SPOUSEOTHERRetiree Full Name(Required) First Middle Last Retiree Gender(Required)MaleFemaleAddress(Required) Street Address Address Line 2 City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Date of Birth(Required)MM slash DD slash YYYY Daytime telephone number(Required) Retiree Social Security Number(Required)Enter a valid SSN. Your Social Security Number is secured with AES-256, encryption used by banks and the military, ensuring utmost safety. Additionally, all data in transit is protected with robust TLS/SSL encryption.Retiree Email Address Enter Email Confirm Email This is to keep in communication after submission. Referral CodeDoes the Retiree Have Dependents Enrolling?(Required) Yes Dependents No DependentsSection II: List Spouse and/or All Dependents That Are EnrollingDependents ListFirst NameMILast NameRelationship to RetireeSexDOBFull-Time Student?Dependent SSN Add RemovePlease list your Spouse (if applicable) or any applicable dependents.Section III: Important NotesYou can find a complete listing of your rates on the included enrollment worksheet. Please reviewthese rates before selecting your coverage. You can find a complete listing of your rates on the included enrollment worksheet. Please review these rates before selecting your coverage. When selecting your coverage please check each box that pertains to the coverage you/dependents are electing. For example, if you are enrolling as a Spouse or Child only, you need to check the appropriate box. All enrollees are eligible if the Retiree is qualified and can enroll as Standalone participants and must complete the Retiree box and the Dependents box Family Coverage is coverage including three or more individuals. Please review all information and sign and date where necessary. If you are a Retiree and/or Spouse and/or Dependent enrolling in the plan as a Single for the best pricing, each family member must complete their own form & pay individually for their plan options. Choose Your Plan Effective Date for Coverage(Required)MM slash DD slash YYYY When do you want your coverage to start?Copper Plan: Standalone Medical and Prescription Drugs with Telemedicine Retiree Spouse Child FamilyBronze Plan: Standalone Medical and Prescription Drugs with Telemedicine Retiree Spouse Child FamilySilver Plan: Standalone Medical and Prescription Drugs with Telemedicine Retiree Spouse Child FamilyGold Plan: Standalone Medical and Prescription Drugs including Dental, Vision and Telemedicine Retiree Spouse Child FamilyDo you want to add dental only? Single FamilyDo you want to add dental and vision? Single Two Person FamilyCopper – Dental & Vision Rates $67.98 /month for Single $135.97 /month for Two People $196.60 /month for Family This is an add-on to your plan.Bronze – Dental & Vision Rates $67.98 /month for Single $135.97 /month for Two People $236.60 /month for Family This is an add-on to your plan.Silver – Dental & Vision Rates $67.98 /month for Single $135.97 /month for Two People $236.60 /month for Family This is an add-on to your plan. Payment InformationPlease provide your bank account details below for payment.Account TypeCheckingSavings Bank Name(Required) Account Number(Required)Your data is secured with AES-256, encryption used by banks and the military, ensuring utmost safety. Additionally, all data in transit is protected with robust TLS/SSL encryption. Confirm Account Number(Required) Bank Routing Number(Required)Enter a valid Bank Routing Number shown at the bottom of your bank checks. Your data is secured with AES-256, encryption used by banks and the military, ensuring utmost safety. Additionally, all data in transit is protected with robust TLS/SSL encryption.Consent(Required) I authorize Solidarity Health Network to debit my bank account for the the amount indicated on the policy.Final SectionPLEASE READ THE FOLLOWING INFORMATION. THE INFORMATION ON THIS FORM AND THE FOLLOWING CONDITIONS ARE PART OF MY CONTRACT WITH BLUE CROSS BLUE SHEILD OF MICHIGAN (BCBSM). I am applying for coverage for myself and my family member identified on this application under my group’s or association’s contract with BCBSM. Coverage begins on the date determined by BCBSM. When BCBSM accepts my application, I and covered members of my family are bound by the terms on the policy and this application. I understand that the submission of false or misleading information or the omission of material information on this form may result in rejection of my enrollment or retroactive termination of my coverage. Proof of eligibility: I agree to provide proof of my dependent’s eligibility for coverage when requested by BCBSM. Authorization: I appoint my group or association to handle all matters of coverage. It may forward deductions from my wages. I am responsible for giving notice to my group or association of changes in my status and/or my family’s status that affect coverage, such as marriage, divorce, birth, Medicare entitlements, or death of someone covered under the policy. I authorize BCBSM and/or my Primary Care Physician to obtain the medical records relating to me and my enrolled family members necessary for the coordination of our medical care, administration of my coverage with BCBSM, and for other purposes necessary for BCBSM to fulfill its contractual and statutory obligations. Release of Information: I acknowledge that BCBSM requires me to provide my Social Security Number. In applying for coverage, I and my enrolled family members agree to permit providers and others to release “protected health information” (as that term is used in the Health Insurance Portability and Accountability Act of 1996, as amended) to BCBSM for purposed of administering our coverage. Upon my request, BCBSM will tell me where the information was sent. Retiree Signature(Required)Please print your name. Spouse Signature (if enrolling)Please print your name.PhoneThis field is for validation purposes and should be left unchanged.
