| Form | Maryland (EXCLUDING PG & Montgomery Counties) | Maryland (ONLY PG & Montgomery Counties ) |
|---|---|---|
| Contract and Benefits Booklet Request Form | CUT6592 | CUT6592 |
| Full-Time Equivalent (FTE) Group Size Calculation Worksheet | FRM6237 | FRM6237 |
| Medicare Secondary Payer (MSP) Calculation Form | FRM4011 | FRM4011 |
| BlueChoice Point of Service Selection | N/A | N/A |
| Enrollment Transaction Report (ETR) | CUT5796 | CUT5795 |
| Waiver of Enrollment | CUT6529 | CUT6529 |
| Confirmation of Enrollment | CUT5802 | CUT5801 |
| Disability Certification for Overaged Dependent | CUT5625 | CUT5625 |
| Primary Caretaker Certification | N/A | N/A |
| COBRA Continuation | CUT5870 | CUT5861 |
| Selection Form for Continuation of Group Coverage | CUT5862 | CUT5872 |
| Proof of Prior Group Dental Coverage for Voluntary Dental | SUM1750 | SUM1750 |
| Affiliated Companies/Common Ownership Certification | CUT9069 | CUT9069 |
Due to a planned data migration beginning Friday, July 11 at 11:00 p.m., and continuing through Monday, July 14 at 8:00 a.m., you may experience a delay in your information appearing on CareFirst portals. We expect that changes to member data will be reflected on the portals by Tuesday, July 15. Your patience is appreciated.
Change Healthcare notifying individuals of data breach. Learn more here.
HealthyBlue PPO - Miscellaneous Forms - Maryland
Miscellaneous Forms - Maryland