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Completing the Blue Cross and Blue Shield of Vermont Enrollment Form
Step 1: Download a copy of the enrollment form.
Step 2: Fill the form out for a new enrollment, to change your membership status, or to cancel your policy.
New Enrollment
Section 1
Section 2
- Check the box that indicates your reason for enrolling
- Complete Date of Event box which will correspond with the Date of Hire in section 1
Section 3
- List all dependents to be covered by your health care coverage, including yourself
- If applying for TVHP (HMO) or VHP you must indicate a Primary Care Physician, ID number and existing patient status for each dependent
- If the dependent(s) is 19 or older complete the student section and indicate the name of the school and its location, the student's begin date and anticipated graduation date
Section 4
- If you or your dependent(s) are covered by another health or dental plan, complete this section
Section 7
- Subscriber's signature and date
Membership Change
Section 1
Section 2
- Check the box that indicates the reason for your change
- Complete the Date of Event box
Section 3
- Only list the dependents that will be affected by this change
- If adding a dependent(s) to a TVHP (HMO) or VHP plan you must indicate a Primary Care Physician, ID number and existing patient status
- If the dependent(s) is 19 or older complete the student section and indicate the name of the school and its location, the student's begin date and anticipated graduation date
Section 4
- If you or your dependent(s) are covered by another health or dental plan, complete this section
Section 7
- Subscriber's signature and date
Cancel Request
Section 1
Section 2
- Check the box that indicates the reason for your cancel
- Complete the Date of Event box
Section 7
- If the subscriber is no longer employed, the Remitting Agent may sign the enrollment form on behalf of the employee
- If the subscriber is employed, but elects to cancel the coverage, the employee must sign the enrollment form
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