Contract Administration Request Form

- - for contract and benefit guide requests - -

Submit this completed form with your installation paperwork to enroll new groups, make benefit changes or submit a service request.

COMMENTS:

SECTION I (GHMSI, CFBC & CFMI)

Group/Account Name:

/

Group/Account #

/

A.E. (Sales Rep):

/

A.M. (Service Rep):

Type of Service Requested:
Electronic version of Benefit Booklets on CD with (check one) 10% 20% 30% production of paper guides*
CD’s Only*
Paper Booklets Only
Draft of GHMSI or CFBC Contract Draft of GHMSI or CFBC Benefit Guide SEND TO: A.E. A.M.

* GHMSI & CFBC – CD’s are available only to new groups and upon renewal. CFMI –CD’s are available at anytime once the signed acceptance page of the contract is received by CareFirst.

SECTION II GHMSI & CFBC
If more than one option per product, indicate the options or medical BSBS codes.
BLUECHOICE / BlueChoice Opt Out Plus / BLUECHOICE ADVANTAGE
Option/BSBS / Quantity / Option/BSBS / Quantity / Option/BSBS / Quantity
BLUECHOICE OPEN ACCESS
(includes BlueFund & HRA/HSA compatible health plans) / BlueChoice
Opt Out Plus OPEN ACCESS
(includes BlueFund & HRA/HSA compatible health plans) / DENTAL ONLY
Option/BSBS / Quantity / Option/BSBS / Quantity / Option/BSBS / Quantity
Traditional
BlueChoice Opt Out Open Access / BluePreferred
(includes BlueFund & HRA/HSA compatible health plans) / VISION ONLY
Option/BSBS / Quantity / Option/BSBS / Quantity / Option/BSBS / Quantity
Vision
List GHMSI Indemnity products here:
Special Mailing Instructions for GHMSI & CFBC benefit guides.
Benefit guides will be mailed to the current physical address on file unless otherwise specified.
Send to broker on file Send to AE Send to AM Other (provide mailing address below in Sec III):
SECTION III CFMI SEGO AND 51+
List products/groups and quantity of benefit guides requested for each product/group.
A signed acceptance page must accompany this form for 51+ and Major accounts.
SEGO
51+
Major Acct
Non-SEGO / Product / Quantity: / This must be completed for all SEGO accounts:
Part-Time employees included? Yes No
Employees with other coverage included? Yes No
Retirees included? Yes No
Product / Quantity:
Product / Quantity:
Product / Quantity:
All requests for CFMI accounts must include a mailing address. Complete the “Mail To” information below:
AE/AM Name: / Broker Name:
Company/Attn to Name:
Physical Address: / Street:
City: / State / Zip

CUT6592-1E (12/06)

CareFirst BlueCross BlueShield is the business name of Group Hospitalization and Medical Services, Inc. CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. 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.