Member Update FormACA and Grandfathered Virginia Members

Group Hospitalization and Medical Services, Inc. CareFirst BlueChoice, Inc.

840 First Street, NE, Washington, DC 20065Mailroom Administrator P.O. Box 14651, Lexington, KY 40512Fax: 410-505-2901 or toll free 800-305-1351

CareFirst BlueCross BlueShield is the business name of Group Hospitalization and Medical Services, Inc. CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are both independent licensees of the Blue Cross and Blue Shield Association.

Registered trademark of the Blue Cross and Blue Shield Association.

If you purchased your insurance directly from CareFirst BlueCross BlueShield and you need to make changes other than what is available on this form, you must fill out an application. If you purchased your insurance directly through the Virginia Health Insurance Marketplace, then you MUST contact them directly to make any changes to your policy.

This is not an application for insurance

Subscribers Last Name First Name M.I. Date of Birth (mm/dd/yyyy) / /

Residence Address (Street) City and State Zip Code

Residence County Subscriber ID# (SID) Group # SSN Phone Number( )

CHANGES REQUESTED (please check box of requested change)

ADDRESS*Residence Address

Street City County State Zip Code

Billing Address

Street City County State Zip Code

Requested Effective Date of Change (mm/dd/yyyy) / / * If moving out of state please contact Sales at 800-544-8703 or your Broker.

PHONE NUMBER

HomeOld Phone Number( )

New Phone Number( )

Work/CellOld Phone Number( )

New Phone Number( )

NAME (legal documentation required)

Change from:Last First M.I.

Change to:Last First M.I.

Name Change Reason: Marriage Divorce Other:

ADD/CHANGE PRIMARY CARE PROVIDER (PCP) INFORMATION

PCP for member:

Last First M.I.

Add/Change to:

PCP#Existing Patient? Yes No

PCP for member:

Last First M.I.

Add/Change to:

PCP#Existing Patient? Yes No

PCP for member:

Last First M.I.

Add/Change to:

PCP#Existing Patient? Yes No

CUT9751-1N (4/16)

2

OTHER HEALTH INSURANCE INFORMATION

Is any person listed on the change form covered by another health care plan or HMO? Yes NoIf yes, will this coverage be continued? Yes No If No, please provide the cancellation date: / /Policyholders Name: Last First M.I.

Name of Insurance Company: Phone Number of Other Insurer

Address of Insurance Company: Street City State Zip

Policy Number Group Number Effective Date of Policy

/ /Name of Employer Providing Coverage (if applicable)

Does this policy cover: You? Yes No Your Spouse/Partner? Yes No Your children? Yes NoPlease list the name(s) of child(ren) covered:

Policyholders working status: Active Retired Retirement date: / /

IF YOU HAVE OTHER HEALTH INSURANCE COVERAGE, FAILURE TO COMPLETE THIS SECTION WILL CAUSE SIGNIFICANT DELAYS IN PROCESSING ANY CLAIMS SUBMITTED.

ELECTRONIC COMMUNICATION CONSENTCareFirst wants to help you manage your health care information and protect the environment by offering you the option of electronic communication.

Instead of paper delivery, you can receive electronic notices about your CareFirst health care coverage through email and/or text messaging by providing your email address and/or cell phone number and consent below.

Electronic notices regarding your CareFirst health care coverage include, but are not limited to:

Explanation of Benefits Alerts Reminders Notice of HIPAA Privacy Practices Certification of Creditable Coverage

You may also receive information on programs related to your existing products and services along with new products and services that may be of interest to you.

Please note: This consent for electronic communications applies to the Primary Applicant only. Spouse/Domestic Partners and dependents 18 years of age and older can consent to electronic communications through www.carefirst.com/myaccount. Members can also change email and consent information anytime by logging into www.carefirst.com/myaccount or by calling the customer service phone number on your ID card. You can also request a paper copy of electronic notices at any time by calling the customer service phone number on your ID card.

I understand that to access the information provided electronically through email, I must have the following:

Internet access; An email account that allows me to send and receive emails; and Microsoft Explorer 7.0 (or higher) or Firefox 3.0 (or higher), and Adobe Acrobat Reader 4 (or higher).

I understand that to receive notices through text messaging,

A text messaging plan with my cell phone provider is required; and Standard text messaging rates will apply.

Primary Applicant Name Email Address Cell Phone Number

Alternate Email Address Alternate Cell Phone Number

By checking below, I hereby agree to electronic delivery of notices, instead of paper delivery by: Email only Cell phone text messaging only Email and cell phone text messaging

Signature: X

CareFirst will not sell your email or phone number to any third party and we do not share it with third parties except for CareFirst business associates that perform functions on our behalf or to comply with the law.

CUT9751-1N (4/16)

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VIRGINIA WARNING: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may have violated Virginia state law.

REQUIRED SIGNATURE(S) AND DATESubscribers Signature Date

/ /

Members Signature Date / /

Parent or Legal Guardians Signature Date / /

RACE, ETHNICITY, LANGUAGE (this information is voluntary)CareFirst is asking its members to voluntarily provide their race, ethnicity and language attributes. The information provided, while voluntary, will assist us to improve quality of care and access to care thereby reducing health care disparities and promote better health outcomes. The information you provide will not have a negative impact on any services we provide you. The information is kept strictly confidential and will not be shared unless required by law to disclose it.

Race Ethnicity Preferred Spoken Language*White/Caucasian Hispanic/Latino/Spanish origin 01 English 09 Farsi 18 RussianBlack or African American 02 Albanian 10 French (European) 19 SerbianAm erican Indian or Alaska Native 03 Amharic 11 Greek 20 SomaliAsian 04 Arabic 12 Gujarati 21 Spanish (Latin America)Native hawaiian or other pacific islander

05 Burmese 13 Hindi 22 Tagalog (Filipino)06 Cantonese 14 Italian 23 Urdu

Other (To include Multi-Racial) 07 Chinese (simplified & traditional)

15 Korean 24 VietnameseDecline to answer 16 Mandarin 98 Other and unspecified

languagesUnknown Could not be determined

08 Creole (Haitian) 17 Portuguese (Brazilian)99 Unknown

Last Name First Name Race EthnicityCountry of

Origin

Preferred Spoken Language

(specify number from above*)

Primary Applicant

Spouse/Domestic Partner

Dependent 1

Dependent 2

Dependent 3

Dependent 4

Dependent 5

Dependent 6

Dependent 7

Dependent 8

CUT9751-1N (4/16)

CareFirst BlueCross BlueShield is the business name of Group Hospitalization and Medical Services, Inc. CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are both independent licensees of the Blue Cross and Blue Shield Association.

Registered trademark of the Blue Cross and Blue Shield Association.

CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., CareFirst BlueChoice, Inc., First Care, Inc. and The Dental Network are independent licensees of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association.

Registered trademark of CareFirst of Maryland, Inc.

Notice of Nondiscrimination and Availability of Language Assistance Services

CareFirst BlueCross BlueShield, CareFirst BlueChoice, Inc. and all of their corporate affiliates (CareFirst) comply with applicable federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability or sex. CareFirst does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. CareFirst:

Provides free aid and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats)

Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages

If you need these services, please call 855-258-6518. If you believe CareFirst has failed to provide these services, or discriminated in another way, on the basis of race, color, national origin, age, disability or sex, you can file a grievance with our CareFirst Civil Rights Coordinator. Civil Rights Coordinator, Corporate Office of Civil Rights Telephone Number 410-528-7820

Mailing Address P.O. Box 8894 Baltimore, Maryland 21224

Fax Number 410-505-2011

Email Address civilrightscoordinator@carefirst.com You can file a grievance by mail, fax or email. If you need help filing a grievance, our CareFirst Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

mailto:civilrightscoordinator@carefirst.comhttps://ocrportal.hhs.gov/ocr/portal/lobby.jsfhttp://www.hhs.gov/ocr/office/file/index.html

CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., CareFirst BlueChoice, Inc., First Care, Inc. and The Dental Network are independent licensees of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association.

Registered trademark of CareFirst of Maryland, Inc.

Foreign Language Assistance Attention (English): This notice contains information about your insurance coverage. It may contain key dates

and you may need to take action by certain deadlines. You have the right to get this information and assistance in

your language at no cost. Members should call the phone number on the back of their member identification card.

All others may call 855-258-6518 and wait through the dialogue until prompted to push 0. When an agent

answers, state the language you need and you will be connected to an interpreter.

(Amharic) -

855-258-6518 0

d Yorb (Yoruba) ttlko: kys y n wfn npa i adjtf r. le n wn dt pt o s le n lti

gb gbs n wn j gbdke kan. O ni t lti gba wfn y ti rnlw n d r lf. wn m-gb

gbd pe nmb fn t w lyn kd dnim wn. wn mrn le pe 855-258-6518 k o s dr npas jrr

tt a fi s fn lti t 0. Ngbt aoj kan b dhn, s d t o f a s so p m gbuf kan.

Ting Vit (Vietnamese) Ch : Thng bo ny cha thng tin v phm vi bo him ca qu v. Thng bo c th

cha nhng ngy quan trng v qu v cn hnh ng trc mt s thi hn nht nh. Qu v c quyn nhn

c thng tin ny v h tr bng ngn ng ca qu v hon ton min ph. Cc thnh vin nn gi s in thoi

mt sau ca th nhn dng. Tt c nhng ngi khc c th gi s 855-258-6518 v ch ht cuc i thoi cho

n khi c nhc nhn phm 0. Khi mt tng i vin tr li, hy nu r ngn ng qu v cn v qu v s c

kt ni vi mt thng dch vin.

Tagalog (Tagalog) Atensyon: Ang abisong ito ay naglalaman ng impormasyon tungkol sa nasasaklawan ng iyong

insurance. Maaari itong maglaman ng mga pinakamahalagang petsa at maaaring kailangan mong gumawa ng

aksyon ayon sa ilang deadline. May karapatan ka na makuha ang impormasyong ito at tulong sa iyong sariling

wika nang walang gastos. Dapat tawagan ng mga Miyembro ang numero ng telepono na nasa likuran ng kanilang

identification card. Ang lahat ng iba ay maaaring tumawag sa 855-258-6518 at maghintay hanggang sa dulo ng

diyalogo hanggang sa diktahan na pindutin ang 0. Kapag sumagot ang ahente, sabihin ang wika na kailangan mo

at ikokonekta ka sa isang interpreter.

Espaol (Spanish) Atencin: Este aviso contiene informacin sobre su cobertura de seguro. Es posible que

incluya fechas clave y que usted tenga que realizar alguna accin antes de ciertas fechas lmite. Usted tiene

derecho a obtener esta informacin y asistencia en su idioma sin ningn costo. Los asegurados deben llamar al

nmero de telfono que se encuentra al reverso de su tarjeta de identificacin. Todos los dems pueden llamar al

855-258-6518 y esperar la grabacin hasta que se les indique que deben presionar 0. Cuando un agente de seguros

responda, indique el idioma que necesita y se le comunicar con un intrprete.

(Russian) !

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CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., CareFirst BlueChoice, Inc., First Care, Inc. and The Dental Network are independent licensees of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association.

Registered trademark of CareFirst of Maryland, Inc.

(Hindi) : - 855-258-6518 0 ,

s-w (Bassa) To uu Cao! B nia k a ny e ke m gbo kpa o ni fu a-fa-tiin ny je dyi. B nia k

ee we j e m ke wa m m ke nyu nyu hw we ea ke zi. m ni kpe m ke b nia k ke gbo-

kpa-kpa m m dye e ni ii-wuu mu m ke se wii o p. Kpoo ny e m a fn-na nia e waa

I.D. kaa ein ny. Ny t sein m a na nia k: 855-258-6518, ke m m fo tee wa ke m gbo c m ke

na ma 0 k dyi paain hw. ju ke ny o dyi m g juin, po wuu m m po dyi, ke ny o mu o niin

ke ni wuu mu za.

(Bengali) : 855-258-6518 0

: (Urdu )

0 6518-258-855

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. 0 855-258-6518

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: (Arabic) . .

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(Traditional Chinese)

855-258-6518

0

CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., CareFirst BlueChoice, Inc., First Care, Inc. and The Dental Network are independent licensees of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association.

Registered trademark of CareFirst of Maryland, Inc.

Igbo (Igbo) Nrbama: kwa a nwere ozi gbasara mkpuchi nchekwa onwe g. nwere ike nwe bch nd d

mkpa, nwere ike me ihe tupu fd bch njedebe. nwere ikike nweta ozi na enyemaka a nass g na

akwgh gw bla. Nd otu kwesr kp akara ekwent d naz nke kaad njirimara ha. Nd z niile nwere

ike kp 855-258-6518 wee chere bb ah ruo mgbe amanyere p 0. Mgbe onye nnchite anya zara, kwuo

ass chr, a ga-ejik g na onye kwa okwu.

Deutsch (German) Achtung: Diese Mitteilung enthlt Informationen ber Ihren Versicherungsschutz. Sie kann

wichtige Termine beinhalten, und Sie mssen gegebenenfalls innerhalb bestimmter Fristen reagieren. Sie haben

das Recht, diese Informationen und weitere Untersttzung kostenlos in Ihrer Sprache zu erhalten. Als Mitglied

verwenden Sie bitte die auf der Rckseite Ihrer Karte angegebene Telefonnummer. Alle anderen Personen rufen

bitte die Nummer 855-258-6518 an und warten auf die Aufforderung, die Taste 0 zu drcken. Geben Sie dem

Mitarbeiter die gewnschte Sprache an, damit er Sie mit einem Dolmetscher verbinden kann.

Franais (French) Attention: cet avis contient des informations sur votre couverture d'assurance. Des dates

importantes peuvent y figurer et il se peut que vous deviez entreprendre des dmarches avant certaines chances.

Vous avez le droit d'obtenir gratuitement ces informations et de l'aide dans votre langue. Les membres doivent

appeler le numro de tlphone figurant l'arrire de leur carte d'identification. Tous les autres peuvent appeler le

855-258-6518 et, aprs avoir cout le message, appuyer sur le 0 lorsqu'ils seront invits le faire. Lorsqu'un(e)

employ(e) rpondra, indiquez la langue que vous souhaitez et vous serez mis(e) en relation avec un interprte.

(Korean) : . .

. ID .

855-258-6518 0 .

.