Pacific Time. To add a child placed for adoption to this Agreement as a Dependent, the Subscriber must contact Blue Shield of California at the Customer Service telephone number listed at the back of this booklet. The Customer Service Department will advise the Subscriber of the exact pro- cess for adding a child place for adoption as a Depend- ent, including, but not limited to, the necessary docu- mentation and how the documentation shall be submitted to Blue Shield of California. Enrollment requests for an adopted child must be accompanied by evidence of the Subscriber's, spouse's, or Domestic Partner’s right to control the child's health care, which includes a facility minor release report, a medical authorization form, or a relinquishment form. If the Subscriber wishes to add a child placed for adop- tion as a Dependent 32 or more days after the date the Subscriber, spouse, or Domestic Partner has the right to control the child’s health care, Blue Shield of California will require the submission of a completed application, and the child will be subject to medical underwriting. This may result in the child being declined coverage by Blue Shield of California.
Appears in 5 contracts
Samples: Health Service Agreement, Health Service Agreement, Health Service Agreement
Pacific Time. To add a child placed for adoption to this Agreement as a Dependent, the Subscriber must contact Blue Shield of California at the Customer Service telephone number listed at the back of this booklet. The Customer Service Department will advise the Subscriber of the exact pro- cess for adding a child place for adoption as a Depend- ent, including, but not limited to, the necessary docu- mentation and how the documentation shall be submitted to Blue Shield of California. Enrollment requests for an adopted a child placed for adoption must be accompanied by evidence evi- dence of the Subscriber's, 's or spouse's, or Domestic 's /Domestic Partner’s right to control the child's health care, which includes a facility minor release report, a medical authorization form, or a relinquishment form. If the Subscriber wishes to add a child placed for adop- tion as a Dependent 32 or more days after the date the Subscriber, spouse, or Domestic Partner has the right to control the child’s health care, Blue Shield of California will require the submission of a completed application, and the child will be subject to medical underwriting. This may result in the child being declined coverage by Blue Shield of California.
Appears in 3 contracts
Samples: Health Service Agreement, Health Service Agreement, Health Service Agreement
Pacific Time. To add a child placed for adoption to this Agreement as a Dependent, the Subscriber must contact Blue Shield of California at the Customer Service telephone number listed at the back of this booklet. The Customer Service Department will advise the Subscriber of the exact pro- cess for adding a child place for adoption as a Depend- ent, including, but not limited to, the necessary docu- mentation and how the documentation shall be submitted to Blue Shield of California. Enrollment requests for an adopted child must be accompanied by evidence of the Subscriber's, spouse's, or Domestic Partner’s right to control the child's health care, which includes a facility minor release report, a medical authorization form, or a relinquishment form. If the Subscriber wishes to add a child placed for adop- tion as a Dependent 32 or more days after the date the Subscriber, spouse, or Domestic Partner has the right to control the child’s health care, Blue Shield of California will require the submission of a completed application, and the child will be subject to the medical underwriting. This may result in the child being declined coverage by Blue Shield of California.
Appears in 2 contracts