Can this form be signed electronically?

Yes. Electronic signatures are enforceable under the ESIGN Act (15 U.S.C. ch. 96) and UETA in most states, provided the signature demonstrates intent, consent, attribution, and retention. Certain rare exceptions may apply to specific document types.

Do I need a notary to enroll?

Typically no for standard insurance enrollments. Notarization is only required when the insurer or state law explicitly requests it. If a signature notarization is required, follow state notary rules or use an approved RON provider where permitted.

What if I made an error after signing?

Contact the plan administrator or broker immediately to request a corrected enrollment form. Some corrections can be handled administratively; others require a new signed form to maintain a clear audit trail.

Who verifies dependent eligibility?

The insurer reviews dependent documentation and may request birth certificates, marriage certificates, or court orders. Submit required proofs promptly to avoid dependent coverage delays.

How long does processing take?

Carrier processing typically takes 7–21 business days after a complete submission. Missing information or manual review increases processing time and may change the effective date.

How is protected health information handled?

Enrollment data containing PHI must be handled under HIPAA privacy and security rules. Use platforms and vendors who sign a BAA and support encryption in transit and at rest.

Electronic Signature
Templates
Education
Enrollment Form CareFirst

Enrollment Form CareFirst

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

Enrollment Form (Virginia Small Groups)

CareFirst BlueCross BlueShield is the business name of Group Hospitalization and Medical Services, Inc., and is an independent licensee of the Blue Cross and Blue Shield Association.

HOW TO COMPLETE THIS FORM:

1. Please type or print clearly with pen.

2. Complete all appropriate items, sign and date.

3. Please return this form to your employer.

4. Employer must complete if Section VII is answered – Number of employees in group:

I. EMPLOYER INFORMATION – To be completed by the employer

Employer / Group Administrator

Effective Date Requested

Group Number

II. ENROLLEE

Social Security Number

Date of Birth

Sex

Male Female

Last Name

First Name

Middle Initial

Date of Hire

Occupation

Employment Status

Full-Time Part-Time Retired

Residence Address (Number and Street) (City and State) (Zip Code – 9-digit, if known)

Home Phone

Work Phone

Marital Status

Single Married Domestic Partner Other Separated Divorced

Tobacco Usage*

Yes No

III. TYPE OF ENROLLMENT

CHECK ONE:

New Coverage Change

IV. PLAN SELECTION

To avoid delays in processing this form, please confirm with your employer the details of the benefit options offered by your employer prior to completing this section.

CHECK ONLY ONE:

BluePreferred PPO HSA/HRA $1,400 BluePreferred PPO HSA/HRA $2,000-SE BluePreferred PPO HSA/HRA $4,000-SE BluePreferred PPO HSA/HRA $4,500 BluePreferred PPO $500 BluePreferred PPO $1,000-SE BluePreferred PPO $1,200 BluePreferred PPO $2,000 BluePreferred PPO $4,500 BluePreferred PPO 100%/80%-SE BluePreferred PPO HSA/HRA $2,000 BluePreferred PPO $1,000, 100%/80% BluePreferred PPO $1,000, 80%/60% BluePreferred PPO 100%/80%

HealthyBlue PPO $300 HealthyBlue PPO $600 HealthyBlue PPO $1,500 HealthyBlue PPO HSA/HRA $2,000

V. CHANGE TO EXISTING ENROLLMENT

Dependents affected by additions or deletions must be listed in Section VI - Dependent Information.

Identification Number, if different from Social Security Number:

ADD dependent(s) listed in Section VI

ADD spouse due to marriage on

ADD domestic partner on

ADD child due to adoption on or appointed legal guardian by court decree dated

(Note: Documentation of adoption or court-appointed legal guardianship must be provided)

REMOVE dependent(s) listed in Section VI due to on

CHANGE address to that shown in Section II

CHANGE my name from to that shown in Section II

VI. DEPENDENT INFORMATION

1. Spouse

Male Female

Yes No

2. Domestic Partner

Male Female

Yes No

3. Child

Male Female

Yes No

4. Child

Male Female

Yes No

5. Child

Male Female

Yes No

6. Child

Male Female

Yes No

COMPLETE ONLY IF CHILD IS A STUDENT OR DISABLED (AGE 26 OR OLDER)

If child is a student age 26 or older, please confirm coverage with your employer prior to completing this section.

Full-Time Student?

Yes No

Disabled?

Yes No

Full-Time Student?

Yes No

Disabled?

Yes No

VII. MEDICARE COVERAGE

FAILURE TO COMPLETE THIS SECTION, IF APPLICABLE, WILL CAUSE SIGNIFICANT CLAIMS PROCESSING DELAYS.

Check this box if any person listed on this form is eligible for or receiving benefits under Medicare.

Name

Reason for entitlement:

Age 65 or older Kidney disease Disabled

Medicare Claim No.

Eligible for Part A Eff. Date

Eligible for Part B Eff. Date

EMPLOYMENT STATUS (CHECK ONLY ONE BOX):

Actively Employed Retired

Name

Reason for entitlement:

Age 65 or older Kidney disease Disabled

Medicare Claim No.

Eligible for Part A Eff. Date

Eligible for Part B Eff. Date

EMPLOYMENT STATUS (CHECK ONLY ONE BOX):

Actively Employed Retired

VIII. PRIOR COVERAGE / OTHER INSURANCE INFORMATION

IF YOU HAVE OTHER INSURANCE, FAILURE TO COMPLETE THIS SECTION WILL CAUSE SIGNIFICANT CLAIMS PROCESSING DELAYS.

Check this box if any person listed on this form is now or has been enrolled within the last 31 days in health care or catastrophic coverage through a Blue Cross and/or Blue Shield Plan, a Health Maintenance Organization, another insurance carrier, or Medicaid.

Is this coverage currently in effect? Yes No

If Yes, will this coverage be continued? Yes No If No, please provide cancellation date

1. Policy Holder’s Name and Social Security Number

Sex M F Date of Birth

2. Name and Location of Insurance Company

3. Policy Number

Policy Covers:

Policy Holder Only Two Persons Family

4. Effective Date of Policy

5. Service(s) Covered:

A. Hospital Services Yes B. Physician Services Yes C. Major Medical (out-of-pocket expenses) Yes D. Separate Drug Program Yes E. Dental Yes F. Eye / Vision Care Services Yes G. Mental Illness Services Yes H. HMO Yes

6. Is coverage through an employer or other group?

Yes No

If Yes, name of employer or other group

7. Is this coverage under COBRA?

Yes No

8. To be completed if the parents live apart and provide medical coverage for their child(ren): Please indicate relationship to child(ren).

PARENT WITH COURT-ASSIGNED RESPONSIBILITY FOR CHILD(REN)’S MEDICAL EXPENSES

PARENT WITH CUSTODY OF CHILD(REN)

IX. PLEASE READ CAREFULLY – THIS SECTION MUST BE DATED AND SIGNED

I hereby enroll, on behalf of myself and each dependent listed above, for the coverage indicated. Coverage will be provided according to the terms and conditions of the contract between CareFirst BlueCross BlueShield and my employer. I agree to be bound by that contract. If subscription charges are required by my employer, I agree to pay current and future charges to my employer.

CareFirst BlueCross BlueShield may rescind or void my coverage only if (1) I have performed an act, practice, or omission that constitutes fraud; or (2) I have made an intentional misrepresentation of material fact. CareFirst BlueCross BlueShield will provide 30-days advance written notice of any rescission of coverage and refund any paid premiums to the group.

Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may have violated Virginia state law.

I have carefully read this form and agree to its terms. The recorded answers on this form are, to the best of my knowledge and belief, full, complete and true as of this date.

This information is subject to verification. Failure to complete any section may delay the processing of your form and/or claims payment.

Enrollee Signature

Date

X. CONSENT TO RECEIVE ELECTRONIC NOTICES

CareFirst BlueCross BlueShield wants to help you manage your health care information and protect the environment by offering you the option of electronic communication.

Instead of paper delivery, you can receive electronic notices about your CareFirst BlueCross BlueShield health care coverage through email and/or text messaging by providing your email address and/or cell phone number and consent below.

Electronic notices regarding your CareFirst BlueCross BlueShield health care coverage include, but are not limited to:

• Explanation of Benefits alerts

• Reminders

• Notice of HIPAA Privacy Practices

• Certification of Creditable Coverage

Please note, you may change your email, cell phone and consent information anytime by logging into www.carefirst.com/myaccount or by calling the customer service phone number on your ID card. You can also request a paper copy of electronic notices at any time by calling the customer service phone number on your ID card.

I understand that to access the information provided electronically through email, I must have the following: Internet access; An email account that allows me to send and receive emails; and Microsoft Explorer 7.0 (or higher) or Firefox 3.0 (or higher), and Adobe Acrobat Reader 4 (or higher).

I understand that to receive notices through text messaging: A text messaging plan with my cell phone provider is required; and Standard text messaging rates will apply.

By checking below, I hereby agree to electronic delivery of notices, instead of paper delivery, by:

Email only Cell phone text messaging only Email and cell phone text messaging

By signing below, I hereby agree to electronic delivery of notices.

Member Name

Signature

Email Address

Cell Phone Number

By signing below, my spouse/partner and any other dependents covered by CareFirst BlueCross BlueShield individually agree to electronic delivery of notices.

Spouse/Partner/Dependent Name

Signature

Email Address

Cell Phone Number

What the Enrollment Form CareFirst Is and When It’s Used

The Enrollment Form CareFirst is the standard member application used to enroll individuals or dependents in CareFirst health plans. It collects identifying information, plan selections, coverage effective dates, and consent for premium billing and information sharing. Many employers, brokers, and individual applicants use this form to start, change, or renew coverage during open enrollment or qualifying life events. Accurate completion is necessary for benefits to be processed, for eligibility checks, and to avoid delays in coverage activation or claims processing.

Why Accurate Completion Matters for Coverage and Compliance

A correctly completed Enrollment Form CareFirst reduces processing delays and ensures eligibility decisions reflect the applicant’s intent. For consumer-facing healthcare enrollment, electronic execution and record retention are governed by federal law (ESIGN Act, 15 U.S.C. ch. 96) and state frameworks (UETA or NY ESRA), and HIPAA privacy protections apply to health information.

Who Typically Completes or Receives This Form

Ensure the person completing the form has authority and accurate documentation to avoid processing errors or requests for corrected forms.

Individual applicants and dependents for personal policies, completing personal and contact details and plan choices.
Employer benefits administrators submitting group enrollments for employees and dependents during onboarding or open enrollment.
Licensed agents or brokers who assist applicants with plan selection and submit enrollment on the applicant’s behalf.

Who Can Sign and Authorize the Enrollment

Primary Enrollee

The individual seeking coverage. Must provide legal name, date of birth, Social Security number or TIN when required, and sign to indicate consent to plan terms. Signatures must demonstrate intent to sign and consent to electronic records where applicable.

Authorized Representative

A parent, guardian, power of attorney, or broker authorized to act for the enrollee. Provide proof of authority when requested. Representatives must include their name, relationship, and contact information and must sign in the designated signature block.

Step-by-Step: Complete and Submit the Enrollment Form

Follow these steps in order to prepare and submit a complete Enrollment Form CareFirst without avoidable delays.

01

Gather Documents: Collect IDs, SSN/TIN, dependent documents.
02

Fill Personal Data: Enter names, addresses, birth dates carefully.
03

Select Plan: Choose plan code and coverage level.
04

Sign and Submit: Sign, date, and send via authorized channel.

How Electronic Submission and Routing Works

Electronic enrollment typically follows an upload, validation, and routing workflow. Each step creates metadata used for audit and tracking.

Upload: Sender uploads completed PDF or form.
Validation: System checks required fields and formats.
Routing: Record is routed to payer or admin for processing.
Acknowledgment: Signed copy and receipt are returned to filer.

How to Configure an Online Enrollment Workflow

Use a consistent workflow mapping to reduce mistakes and ensure all required approvals are captured.

Field	Configuration
Required Fields	Mark name, DOB, SSN, address as required
Signer Order	Primary enrollee then authorized rep
Authentication	Use email or SMS code for signer identity
Notifications	Enable email confirmations and document copies

Digital Signing and Distribution Channels

Choose a platform that supports secure transport, audit trails, and necessary integrations with payroll, benefits administration, and document storage to simplify reconciliation and recordkeeping.

Supported Formats: PDF, DOCX
Integrations: HRIS and CRM platforms
Authentication: Email, SMS, KBA

Core Sections to Include on a Professional Enrollment Form

A complete form groups identifying information, coverage choices, dependent data, payment instructions, consent, and signature blocks into clear sections for easy review and processing.

Applicant Details

Full legal name, date of birth, SSN/TIN, contact phone and email. Accurate identification fields are required for eligibility and verification.

Coverage Selection

Plan name, tier (employee, family), effective date, and any rider options. Use exact plan codes when available to prevent misassignment.

Dependent Information

Dependent names, relationships, dates of birth, and SSNs. Include supporting documentation when requested for newborns or newly added dependents.

Premium Payment

Payment method, billing frequency, payroll deduction authorization, and initial premium information if applicable.

Authorizations

HIPAA release, premium billing consent, and application attestations. Consumer-facing disclosures must be presented per ESIGN consumer consent rules.

Signature Area

Designated signature and date fields for enrollee and authorized representative with printed name and relationship fields.

Required Information and Common Field Labels

Member Name: First, middle, last

Date of Birth: MM/DD/YYYY

SSN / TIN: No dashes preferred

Address: Street, city, state, ZIP

Plan Code: Exact plan identifier

Signature: Signed and dated

Consequences of Incorrect or Incomplete Enrollment Data

Coverage Delay: Processing hold or postponed effective date

Premium Miscalculation: Incorrect billing amounts

Claim Denial: Benefits may be denied

Tax Issues: Incorrect 1095 reporting risk

Privacy Violation: HIPAA compliance exposure

Fraud Flag: Potential audit or investigation

Common Errors to Avoid When Preparing the Form

Entering nicknames or abbreviated legal names instead of full legal names leads to identity mismatches and verification requests.
Using the wrong date format or omitting the effective date can result in incorrect coverage start dates and premium prorations.
Failing to include dependent Social Security numbers or proof of relationship often causes pending or denied dependent coverage.
Submitting unsigned forms or using initials where a full signature is required will cause the carrier to reject the enrollment.

Key Deadlines and Typical Processing Times

Enrollment timing varies by context: employer group open enrollment, special enrollment periods, and new hire windows each have distinct deadlines.

Open Enrollment Window:

Dates set by employer or carrier; missing window delays coverage

Special Enrollment Period:

Usually 30–60 days after qualifying event

New Hire Enrollment:

Typically within 30–60 days of hire

Carrier Processing Time:

7–21 business days typical

Effective Date Changes:

Handled per plan rules and carrier policy

eSignature Vendor Pricing Snapshot for Enrollment Workflows

Comparing baseline pricing and common enterprise features helps choose an eSignature provider for high-volume enrollment processing; signNow is listed first for parity with ground-truth pricing.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	Varies by vendor	Varies by vendor	Varies by vendor	Varies by vendor
Bulk Send	Yes	Yes	Yes	Yes	Yes
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No
Envelope Cap	No cap	100 envelopes/user/year	Varies by plan	Varies by plan	Varies by plan

Frequently Asked Questions About the Enrollment Form CareFirst

Answers to common questions about completing, signing, and submitting the Enrollment Form CareFirst to reduce processing errors and ensure compliance.

Need help? Contact support

Can this form be signed electronically?
Yes. Electronic signatures are enforceable under the ESIGN Act (15 U.S.C. ch. 96) and UETA in most states, provided the signature demonstrates intent, consent, attribution, and retention. Certain rare exceptions may apply to specific document types.
Do I need a notary to enroll?
Typically no for standard insurance enrollments. Notarization is only required when the insurer or state law explicitly requests it. If a signature notarization is required, follow state notary rules or use an approved RON provider where permitted.
What if I made an error after signing?
Contact the plan administrator or broker immediately to request a corrected enrollment form. Some corrections can be handled administratively; others require a new signed form to maintain a clear audit trail.
Who verifies dependent eligibility?
The insurer reviews dependent documentation and may request birth certificates, marriage certificates, or court orders. Submit required proofs promptly to avoid dependent coverage delays.
How long does processing take?
Carrier processing typically takes 7–21 business days after a complete submission. Missing information or manual review increases processing time and may change the effective date.
How is protected health information handled?
Enrollment data containing PHI must be handled under HIPAA privacy and security rules. Use platforms and vendors who sign a BAA and support encryption in transit and at rest.

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