1. health and fitness
2. disease

MyChoice Individual Health Coverage
Application
Important Instructions
• Please print legibly in ink or type.
•BlueChoice HealthPlan must receive the application within 30 days of the effective date.
• The application must be signed where indicated.
• Incomplete or illegible applications will be returned.
• Premiums are due before the first of every month.
•Send the completed application and check for the first month’s premium to BlueChoice HealthPlan,
AX-410, P.O. Box 6170, Columbia, SC 29260-6170.
•For more information and the fastest response, apply online at MyChoiceSC.com. If you are paying by
credit card, you must apply online.
Coverage does not become effective under any circumstances until BlueChoice HealthPlan has approved the
application. Coverage will begin the first day of the month after the application has been approved.
10033 (Rev. 4/13)
This coverage is available to applicants age 19 and older. Applicants under age 19 may only be added if the Optional Family Coverage is purchased.
Requested Effective Date:
/ 01
/
M Optional Family Coverage – must have family members at time of application.
(First day of the month after BlueChoice HealthPlan
approved the application.)
section A: information about the applicant
Last Name:
First Name:
Applicant’s Date of Birth: ______/______/______
Is the applicant a resident of South Carolina?
Middle Initial:
M Male
M Female
Telephone Number: Home/Cell: __________________________ Work: ____________________________
M Yes M No Applicant’s Social Security Number:
MMM-MM-MMMM Height:_______ Weight:_____
Address:
City:
County:
State:Zip:
Email Address:
Billing Address for Premium Notices (if different from mailing address):
Address:
City:
County:State:
Zip:
section B: plAn selection
The benefit period begins on the date the coverage goes into effect and lasts 365 days except for leap year.
MyChoice:
Single Coverage:
Deductible:
Coinsurance:
Coinsurance Max:
In network
Out of network
M $ 500
80%
$2,000
$ 4,000
M $ 750
80%
$2,500
$ 5,000
M $1,000
80%
$3,000
$ 6,000
M $3,250
80%
$3,250
$ 6,500
M $1,500
70%
$5,000$10,000
M $2,500
70%
$5,000$10,000
M $3,000
100% HDHP
NA
$10,000
M $5,000
100% HDHP
NA
$10,000
Family Coverage:
Deductible:
Coinsurance:
Coinsurance Max:
In network
Out of network
M $ 1,500
80%
$ 4,000
$ 8,000
M $ 2,250
80%
$ 5,000
$10,000
M $ 3,000
80%
$ 6,000
$12,000
M $ 9,750
80%
$ 6,500
$13,000
M $ 4,500
70%
$10,000
$20,000
M $ 7,500
70%
$10,000
$20,000
M $ 6,000
100% HDHP
NA
$20,000
M $10,000
100% HDHP
NA
$20,000
MyChoice Value Plans:
Single Coverage:
Deductible:
Coinsurance:
Coinsurance Max:
In network
Out of network
M $1,000
80%
$ 5,000
$10,000
M $1,500
70%
$ 6,000
$12,000
M $2,500
70%
$ 7,500
$15,000
M $3,500
70%
$10,500 $21,000
M $5,000
70%
unlimited unlimited
Family Coverage:
Deductible:
Coinsurance:
Coinsurance Max:
In network
Out of network
M $ 3,000
80%
$10,000
$20,000
M $ 4,500
70%
$12,000
$24,000
M $ 5,000
70%
$15,000
$30,000
M $ 7,000
70%
$21,000
$30,000
M $10,000
70%
unlimited unlimited
section C: banking information
M Monthly Bank Draft – Voided Check (not deposit slip) and Authorization Form required.
M Direct Bill
M Monthly Credit Card – (Apply online to pay by credit card.)
10033 (Rev. 4/13)
section D: family information – If Optional Family Coverage Is Selected
Coverage is available for dependent children through age 25. List dependents to be insured.
Last NameFirst NameM.I.Social Security NumberSex
Spouse:
Dependent:
Dependent:
Dependent:
MMM - MM - MMMM
MMM - MM - MMMM
MMM - MM - MMMM
MMM - MM - MMMM
Birth DateHeight
/
/
/
/
/
/
/
/
Weight
M Check here if others are to be insured. List all pertinent information on another sheet.
section E: medical history
In the last 10 years, have you or any person listed on the application had a diagnosis of, advice for, testing for, indication of, symptoms related to, treatment or
surgery for, or any injury related to any of the following?
Pap smears, please provide a copy of your last Pap smear result.) b) Breast
1. M Yes M No Any arthritis (specific type), fibromyalgia, lupus, connective
disorders, fibrocystic diseases, breast implant (saline or silicone) Please
tissue disease, gout, osteoporosis, degenerative joint or disc disease, spina
specify. _______________________________________________
bifida, polio or temporal mandibular (TMJ) disorder. Any disease or injury,
including fractures, dislocations and bone disorders secured with/without
11.
M Yes M No Nephritis, kidney stones, kidney reflux, bladder infections,
pins or screws. Any disease or injury to joint(s) including back, neck and
kidney infections, blood in urine or any other diseases or disorder of the
spine, such as diminished range of motion in the joints (if yes, please
bladder, kidneys or urinary system.
indicate the joint(s) affected). Any loss of limb. Any disorder or injury to
12.
M Yes M No Any type of cancer, tumors, cysts, polyps or other growth.
tendons, including diminished range of motion.
If Yes, please provide the location.
2.
M Yes M No Chest pain, shortness of breath, heart murmur, irregular
M Yes M No Crossed eyes, detached retina, retinopathy, cataract,
heartbeat, heart attack, congestive heart failure, rheumatic fever, heart valve 13.
glaucoma or any other eye injury or disorder.
disorder, aneurysm, high cholesterol, high blood pressure or any other
heart disorder.
14.
M Yes M No Allergies (including allergy shots), hay fever, asthma,
emphysema, cystic fibrosis, pleurisy, tuberculosis, chronic bronchitis,
3. M Yes M No Anemia, leukemia, hemophilia, varicose veins, clots, phlebichronic cough, chronic obstructive pulmonary disease or any other disease
tis, poor circulation or any other vein, artery or blood disease or disorder.
or disorder of the lungs or respiratory system.
4. M Yes M No HIV infection, AIDS, AIDS related complex (ARC) or tested
15.
M Yes M No Nervous, mental or emotional conditions, attempted
positive for HIV or other diseases related to the immune system other
suicide, depression of any of the following disorders: bipolar/manic, anxiety,
than HIV.
schizophrenia, attention deficit (hyperactivity) disorder, anorexia or bulimia,
5. M Yes M No Any disease or disorder of the esophagus, stomach,
mental retardation. Individual, marital or family counseling. If any counselintestines, bowels, rectum, gallbladder, pancreas or spleen; including reflux,
ing received, provide date of last visit. If Yes, frequency of visits, (circle
heartburn, gastritis, diverticulitis, diverticulosis, hernia, colitis, hemorrhoids,
one) Weekly, Monthly, Other
ulcerative colitis, Crohn’s disease or liver disorder including cirrhosis or
(Please explain)._____________________________________________
Hepatitis A, B or C.
16.
M Yes M No Any other abnormality, deformity or congenital birth defect
6. M Yes M No Ear infections, Meniere’s disease, hearing impairment,
not listed which you or any person applying for coverage now have or have
deviated nasal septum, sinusitis, sinus problems or any other disorder of
received treatment for in the last 10 years?
the ear, nose or throat.
17.
M Yes M No Have you or any person applying for coverage been treated
7. M Yes M No Diabetes, hypoglycemia, thyroid disorder, goiter, pituitary
or counseled due to use of these substances in the last five years:
disorder or any other disorder of the glands including metabolic syndrome,
a.Use of alcohol, sedatives, hallucinogens, illegal substances, narcotics or
sugar, blood or albumin in urine, insulin resistance.
any other drugs, other than those prescribed by a physician?
b.
If Yes to any items in (a) please indicate types of treatment and dates.
8. M Yes M No Cystic acne, actinic keratosis, psoriasis, eczema, severe
Date and Type of Treatment: __________________________________
burn, severe scars or any other skin disorder/condition.
c.Been convicted of a DUI in the last five years?
9. M Yes M No Any disorder of the brain, nervous system, including
18.
M Yes M No Within the last 12 months have you or any person applying
chronic fatigue syndrome, epilepsy, seizures, convulsions, fainting spells,
for coverage been advised to have surgery, treatment, tests or studies that
dizziness, Lyme disease, meningitis, multiple sclerosis, muscular dystrophy,
have NOT YET BEEN PERFORMED?
cerebral palsy, sleep disorders, paralysis, Alzheimer’s, Parkinson’s disease,
stroke, TIAs (transient ischemic attacks), migraine or recurrent headaches.
19.
M Yes M No Have you or any person applying for coverage taken
If Yes to seizures or convulsions, provide date of last episode.
medication, or been advised to take medication, within the last year? If Yes,
list all medications in Section F.
10. M Yes M No a) Disorder of the male or female reproductive organs
including enlarged prostate, prostatitis, menstrual irregularities or disorder,
endometriosis, fibroid uterus (benign tumor or mass in or on the uterus),
abnormal pap smear, ovarian cyst, polycystic ovaries, pregnancy complications or sexually transmitted diseases. Infertility or impotency. (If abnormal
10033 (Rev. 4/13)
20.Please provide details for any person listed who has a weight gain/loss of
more than 5 pounds in the last six months.
Name_________________________________ ______ # gained/loss
reasons for weight loss_______________________________________
21.
M Yes M No Are you or any family member or dependent currently pregnant or in the process of adoption? (Including any dependent not applying for
coverage?) If Yes, Name: _________________________________________________________________________________________
Due Date: ______________________________ Relationship to Applicant:__________________________________________________
22. M Yes M No Have you or any person applying for coverage ever smoked or used tobacco products, including cigarettes, cigars, pipes or chewing tobacco in
the last year? If Yes, for how long? _____________ How much used daily? ______________
If no longer using tobacco products, when did you quit?___________________________
Please check appropriate box to answer questions. If “Yes” box is checked, please explain completely and in detail in the space provided in section F.
section F: Details for medical and medication history
Question
Letter/
Number
Patient’s
Name
Condition, Injury,
Symptom or Diagnosis
Date of
Onset
Date of
Recovery
Date
Last
Seen
Treatment, X-ray, Labs,
Surgery, Medication and
Dosage
Name and Phone Number of
Physician or Hospital
Name __________________________
Phone__________________________
Name __________________________
Phone__________________________
Name __________________________
Phone__________________________
Name __________________________
Phone__________________________
List ALL medications taken within the last 12 months by any family member listed on this application.
Family Member
Medication/Dosage/Frequency
(i.e., Lopressor/100mg/daily)
Illness for Which Medication Is Prescribed
Date
Prescribed
(Mo/Day/Yr)
Date
Discontinued
(Mo/Day/Yr)
Name and Phone Number of
Physician or Hospital
Name _________________________
Phone_________________________
Name _________________________
Phone_________________________
Name _________________________
Phone_________________________
section G. other insurance information
M Yes M No
1. Do you or does any member of your family to be insured have other health insurance coverage, including Medicare, Medicare Advantage or
TRICARE in force within the last six months?
a. If Yes, will this policy replace that health insurance?_____________________________________________________
b. Provide a copy of the other carrier’s Certificate of Creditable Coverage as soon as possible.
M Yes M No
2.Have you or any member of your family to be insured been insured by BlueCross® BlueShield® of South Carolina or BlueChoice® HealthPlan of
South Carolina, Inc., in the last three years?
10033 (Rev. 4/13)
a. If Yes, who and under what Social Security Number?______________________________________________________________________
section H. Authorization and Agreements – Read carefully before signing.
The undersigned authorize(s) release to BlueChoice HealthPlan of South Carolina, Inc. (Corporation) or its representatives of (1) All past and future medical records and
other information deemed necessary by the Corporation to underwrite this application and to process claims and (2) All Medicare Part A and Part B claims information
from the effective date of any coverage which may be approved pursuant to this application until the termination of such coverage for the purpose of processing claims.
It is fully understood and agreed (1) That the Corporation has the right to accept, rider and charge an additional premium to or reject any person applying for coverage in
this application, subject to the Patient Protection and Affordable Care Act and (2) If the Corporation approves coverage, the Corporation will determine the effective date
of such coverage, and (3) That no insurance coverage shall be in force until the Corporation receives the application, approves coverage and assigns the date on which
coverage shall become effective, and (4) If coverage is approved, the undersigned will receive an identification card(s) from the Corporation, and (5)That any premium
or policy fee submitted herewith may be retained by the Corporation pending approval of coverage. If any coverage is approved, the Corporation will retain the premiums
thereof and the policy fee. If no coverage is approved, the Corporation will return any premium or fee paid.
The undersigned hereby expressly acknowledges understanding this policy constitutes a policy solely with BlueChoice HealthPlan of South Carolina, Inc., which is an
independent corporation operating under a license from the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
The “Association” permits BlueChoice HealthPlan to use the Blue Cross and Blue Shield service marks in the State of South Carolina, and BlueChoice HealthPlan is not
contracting as an agent of the Association. The undersigned further acknowledges and agrees to have not entered into this policy based on representations by any person
other than BlueChoice HealthPlan of South Carolina, Inc. No person, entity or organization other than BlueChoice HealthPlan shall be held accountable or liable to the
undersigned for any of BlueChoice HealthPlan’s obligations created under this policy. This paragraph shall not create any additional obligations whatsoever on the part of
BlueChoice HealthPlan other than those obligations created under other provisions of this agreement.
The undersigned hereby represent(s) that the information on this application and any other information furnished by the undersigned is complete, true and correctly recorded.
section I. signature(s)
I have read and I fully understand each and every part of this application for insurance.
X
Applicant’s Signature
Date Signed
X
Spouse’s Signature (Only required if applying for coverage) Date Signed
M Check here if dependent (over age 18). Signatures are required.
X
Dependent’s Signature Date Signed
X
Agent’s Signature
MMM - MMM
Date Signed Agent Code
section J. Authorization Agreement for Bank Draft Payments
M bank DraftBank’s Name:Bank Routing Number:
City:
State:
Bank Account No.:
ZIP:
Name on Account:
Draft Date: M 1st of the month
If you choose Bank Draft, complete the authorization agreement below and attach a voided check, if applicable.
Corporation Name: BlueChoice HealthPlan of South Carolina, Inc.
I authorize BlueChoice HealthPlan to initiate debit entries to my checking account below and the Bank/Corporation named to debit my account.
This authority is to remain in force until the Bank/Corporation has received written notification from me of its termination in such time and such manner as to afford the
Bank/Corporation a reasonable opportunity to act on it. A customer has the right to stop payment of a debit entry by notifying the Bank/Corporation. If, within 15 calendar
days following the date on which the Bank/Corporation sent to the customer a statement of account or written notice pertaining to the entry or 46 days after posting, whichever occurs first, the customer shall have sent to the Bank/Corporation a written notice identifying the entry, stating that the entry was in error and requesting the Bank/
Corporation to credit the amount to his/her account.
YOUR NAME:
SIGNED: X
10033 (Rev.4/13)
DATE:
BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association