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C12914-FF10-18SBM-10-18-EmployeeApplications-FF

C12914-FF10-18SBM-10-18-EmployeeApplications-FF 2025

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The document is a Small Business Employee Enrollment Form for Blue Shield of California, effective October 1, 2018. It collects subscriber information, reasons for application (such as new enrollment or qualifying events), health plan selections, and specialty benefits like dental and vision coverage. The form also includes sections for dependent information, COBRA enrollment, and privacy practices regarding personal information. Additionally, it provides language assistance services and nondiscrimination notices.

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What is a health and dental form used for?

The forms provide information on dental home and current oral health status, and what oral health care services were delivered during the dental visit. These services include diagnostic and preventive services, counseling, restorative and emergency care, and referral to a specialist for care.

What is the purpose of an enrollment form?

Enrollment forms record whether employees have enrolled in or waived group benefits. For instance, if you have more than 50 full-time employees, you will need this data to complete IRS forms 1094 and 1095, which record health care coverage.

What is a health dental enrollment forms purpose?

This enrollment form allows individuals to apply for group health and dental coverage. Its designed for employees to provide necessary personal information, dependent details, and coverage choices.

What is the purpose of a health insurance claim form?

They ensure patients healthcare costs are covered, providing financial security. Insurance companies use these forms to verify services and process claims accurately. Healthcare providers rely on these forms to receive prompt payment for their services.