Individual Client New Policy Offer Acceptance Form
You can tell us which option your clients chose by completing the form below. They have more time to make a decision – until 11/15/13 for January renewals and until 11/30/13 for all other clients.
NOTE: It is important to prioritize your January renewals and submit them to us ASAP. Otherwise, January renewals may receive a bill for an ACA-compliant plan that they may not want.
Your clients who received the New Policy Offer are listed on the Individual client report we sent to you recently. These clients have a “Yes” in the New Policy Offer column. Their renewal date is listed in the Renewal Date column.
I affirm that the clients listed below elect to make the following decisions regarding their health care coverage options and that I have maintained a record of my conversation and/or correspondence with each client documenting his/her decision regarding the New Policy Offer at my place of business.
YOUR NAME:AGENCY:
PHONE #: / EMAIL:
Member Name / Member HCID# / Member DOB
(mm/dd/yyyy) / Member Renewal Month / Accepts New Policy Offer / Rejects New Policy Offer / Date
Please email this form to with SECURE in the subject line. Please keep a copy of that sent email for your records.
Anthem Blue Cross and Blue Shield is the trade name of: In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc.RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Ohio: Community Insurance Company. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWi), whichunderwrites or administersthe PPO and indemnity policies; Compcare Health Services Insurance Corporation (Compcare),which underwritesor administers the HMO policies; andCompcareand BCBSWicollectively, which underwriteor administer thePOS policies.Independent licensees of the Blue Cross and Blue Shield Association. ®ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are the registered marks of the Blue Cross and Blue Shield Association.