3108 (W0212) An independent licensee of the Blue Cross and Blue Shield Association. Conversion Request Form (one form per product change) Group Name: _____________________________________________________________________________________ Group Number: ____________________________________ Effective Date: _____ / _____ / ________ Renewal Date (Internal Use Only): _____ / _____ / ________ MM Y Y Y Y D D M M Y Y Y Y D D Broker Name: _____________________________________ Vendor Number: _________________________________ If census is changing, please include enrollment forms for new employees and/or any contract changes for existing members. Please provide employee name and selected Primary Care Physician (if applicable). PCP (if applicable) Current Subgroup # New Subgroup # Employee Name (J or K codes only) (Internal Use Only) (Internal Use Only) * Please note that unless notified, all groups will be set up for one bill option. ** Please submit quote with the Conversion Request Form. Comments: Group Signature: _________________________________________________________ Date: _____ / _____ / ________ MM DD YYYY Account Consultant Signature: ______________________________________________ Date: _____ / _____ / ________ MM DD YYYY You may complete the required fields below online and then save or print a copy for submission. To save a completed copy to your computer, choose File > Save As to rename the file and save the form with your information to your computer.
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3108 (W0212) An independent licensee of the Blue Cross and Blue Shield Association.
Conversion Request Form(one form per product change)
Group Name: _____________________________________________________________________________________
Group Number: ____________________________________
Effective Date: _____ / _____ / ________ Renewal Date (Internal Use Only): _____ / _____ / ________MM YYYY DD MMYYYY DD
Broker Name: _____________________________________ Vendor Number: _________________________________
If census is changing, please include enrollment forms for new employees and/or any contract changes forexisting members.
Please provide employee name and selected Primary Care Physician (if applicable).
PCP (if applicable) Current Subgroup # New Subgroup #Employee Name (J or K codes only) (Internal Use Only) (Internal Use Only)
* Please note that unless notified, all groups will be set up for one bill option.** Please submit quote with the Conversion Request Form.
Comments:
Group Signature: _________________________________________________________ Date: _____ / _____ / ________MM DD YYYY
Account Consultant Signature: ______________________________________________ Date: _____ / _____ / ________MM DD YYYY
You may complete the required fields below online and then save or print a copy for submission. To save a completed copy to your computer, choose File > Save As to rename the file and save the form with your information to your computer.
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