For on-exchange policies, please visit your carrier's website:
For off-exchange policies, please view your carrier's application agreement below:
Blue Shield of California Application Agreement
Authorizations, terms, and conditions Please read the following terms and conditions carefully. Each applicant age 18 and older is required to review the completed application and provide their own authorization and signature. Keep a copy of this application for your records.
Application for coverage: It is important to know that Blue Shield of California or Blue Shield of California Life & Health Insurance Company (as applicable) may decline your application for coverage if you are not currently eligible. Your application must be approved by Blue Shield, and an effective date for coverage assigned, before coverage may become effective.
First month’s dues/premium: Blue Shield requires first month’s dues/premium at the time of application submission. Find your estimated monthly dues/premium by going to blueshieldca.com or contact your agent. Refer to Part 7 for payment options. Failure to submit full payment of dues/premiums will result in a return of your application. Please note that processing any payment does not constitute approval of your application with Blue Shield or Blue Shield Life. If you do not currently qualify for coverage, the dues/premium you submit with your application will not be processed. If you include a check, it will be destroyed.
Past due premiums: Blue Shield reserves the right to collect any unpaid premiums for coverage in the 12-month period preceding the effective date of new coverage before issuing new coverage.
Dues/premiums: Dues/premiums are to be paid in full by the due date. Coverage will be terminated for failure to pay dues/premiums in a timely manner as set forth in the health service agreement/policy and as allowed by law.
(Required) By checking this box 𞠡 , I acknowledge and agree to the following Blue Shield Premium Payment Policy. I also attest that either I, or an Acceptable Third Party Payor, am making and will make all future premium payments for my Blue Shield coverage:
The Subscriber is responsible for payment of dues/premiums to Blue Shield of California. Blue Shield of California does not accept direct or indirect payments of dues/premiums from any person or entity other than the Subscriber, family members or a legal guardian, or an “Acceptable Third Party Payor.” Acceptable Third Party Payors are: Ryan White HIV/AIDS programs under Title XXVI of the Public Health Services Act Indian tribes, tribal organizations or urban Indian organizations A lawful local, State, or Federal government program, including a grantee directed by a government program to make payments on its behalf. Bona fide charitable organizations and organizations related to the Subscriber (i.e., church or employer) when the following is also true: payment is guaranteed for the plan year, assistance is provided based on defined financial status criteria and health status is not considered, the organization is unaffiliated with a healthcare provider, and the organization has no financial interest in the payment of a health plan claim. Financially interested institutions/organizations include institutions/organizations that receive the majority of their funding from entities with a pecuniary interest in the payment of health insurance claims, or institutions/organizations that are subject to direct or indirect control of entities with a pecuniary interest in the payment of health insurance claims. Upon discovery that dues/premiums were paid directly or indirectly by a person or entity other than those listed above or the Subscriber, Blue Shield of California has the right to reject the payment and inform the Subscriber that the payment was not accepted and that the dues/premiums remain due. Processing any payment does not waive Blue Shield of California’s right to reject that payment and future payments under this policy.
Effective date of coverage: If you qualify for coverage, Blue Shield will notify you of your effective date of coverage. If Blue Shield cannot honor your requested effective date, or is unable to issue coverage before your requested date, coverage will begin as soon as possible. If additional dues/premiums are owed, payment must be received before coverage becomes effective. Any charges incurred for services received prior to your effective date or after termination of coverage are not covered.
Effective dates for a special enrollment period may be different than for an open enrollment period. These effective dates are assigned by Blue Shield and may be as early as the 1st of the month following the receipt of the special enrollment period as required by regulation, or the date of birth in the case of a newborn. For information on special enrollment period effective dates, please contact Blue Shield. 6. Acceptance of application: You understand that only Blue Shield can accept your application and issue coverage for an IFP plan requested on this form. Your agent or broker cannot enroll you for coverage or change any terms or conditions of coverage. 7. Parents/guardians: If you are the parent or legal guardian of an applicant who is a minor, please sign on behalf of the applicant at the bottom of this Part 5. As the parent or legal guardian, you are identified as the person who may make inquiries and act on behalf of the applicant regarding this coverage (as allowed by law). In addition, you are agreeing to assume all responsibility for dues/premiums payments and for following the terms and conditions for coverage. If you are not the parent of the applicant, please attach the court documents that appoint you as the guardian of this minor. 8. Authorization for spouse/domestic partner to make changes: If you are an applicant whose spouse/domestic partner is also applying for coverage, please specify if you authorize your spouse/domestic partner to make changes to the contract/policy on your behalf. You may discontinue this authorization at any time by sending a written request to Blue Shield. 9. Authorization for your agent to provide/obtain information: Check here if you do not authorize your insurance agent, broker, or producer (referred to as “your agent”) to access all information on this application. 10. Process to authorize Blue Shield to release personal and health information to a third party: If you would like to authorize your spouse, domestic partner, or a third party to access your personal health information, please complete the form titled Authorization for Blue Shield to Disclose Personal & Health Information to a Third Party. To obtain this form, go to blueshieldca.com and click on the Privacy link at the bottom of the page, or call (888) 256-3650. 11. Response to requested information: You agree to cooperate with Blue Shield (or Blue Shield Life, as applicable) by providing, or by providing access to, documents and other information requested (such as court orders to provide dependent coverage, etc.) to corroborate information provided in this application for coverage. You acknowledge and agree that failure or refusal to provide these documents or the information requested may be cause to rescind or cancel your coverage. 12. Receiving materials and communications electronically versus print: You will receive required benefit plan and coverage-related materials and communications via email and/or the Blue Shield website blueshieldca.com, as applicable. Documents that are made available to you via blueshieldca.com are as follows: • Blue Shield Identification (ID) card • Evidence of Coverage and Health Service Agreement (EOC)/Policy • Statement of Benefits (SOB) • Summary of Benefits and Coverage (SBC) • Endorsements to your EOC or Policy Obtaining a document electronically will confirm your consent to electronic delivery. You also have the right to obtain printed, mailed materials at any time and at no expense to you. To receive printed materials in the mail, to opt out of email communications, or if you have questions, please call (888) 256-3650.
I have reviewed all responses pertaining to me in this application. I have read the benefit summary, Summary of Benefits and Coverage (SBC), and the terms and conditions of coverage and authorizations set forth above. With my own signature below, I represent that the information provided in this application is complete and accurate to the best of my knowledge, and I understand and agree to the terms and conditions of coverage and the authorizations I have provided. (Important: Each adult applicant must provide their own signature.) I understand that I must inform Blue Shield if anything changes or is different from what I listed on this application before my enrollment with Blue Shield begins.