Blue Cross & Blue Shield of Rhode Island Online Application
Direct Pay Medical Underwriting Addendum
Print this addendum now so you have a copy for your records.
Underwriting agreementBy signing this application electronically, I authorize Blue Cross to:
- Request any provider to give Blue Cross all health information about me or my eligible minor dependents for whom coverage is requested, which may include:
- Treatment plans,
- Dates of services,
- Nature of accident or sickness,Record of surgery, and,
- Lab test results, including HIV.
- Use health information to verify the information relevant to this application.
- Use the information in this form to invite me or any of my eligible dependents to take part in medical management, case management, and/or disease management programs. This authorization is valid for 24 months from the date below. By signing this form, I further understand this authorization can be withdrawn at any future time by notifying Blue Cross in writing; the withdrawal:
- Will not affect the rights of anyone acting on it prior to notice.
- May affect my eligibility for the preferred rate program.
- Notice must be sent to:
- Blue Cross & Blue Shield of Rhode Island
- 500 Exchange Street, Providence, Rhode Island 02903-2699
- Attn: Small Group and Dental Underwriting Department
I hereby certify that I have read the above statements, or they have been read to me, and that they are ture and complete. If anyone knowningly lied or hid the truth BCBSRI will have the right to deny claims or void the contract. Also, any benefits previously paid will be subject to collection by BCBSRI