Downloadable Forms for 151+ Employees
BlueCare Dental - HMO
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Form Name
|
Form Number
|
Date
|
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General Notice of Special Enrollment Rights |
#22963 |
04/15 |
|
Notice of Information Practices |
#EB4644 |
03/04 |
|
HIPAA Notice of Privacy Practices |
|
|
|
Standard Authorization Form and other HIPAA Privacy Forms |
|
|
|
Affidavit of Domestic Partnership |
#20551 |
01/05 |
|
Statement of Termination of Domestic Partnership |
#20560 |
02/07 |
|
Tax Information on Health Benefits for Domestic Partnership |
#20559 |
02/07 |
|
Employer New Business Checklist |
#20910
|
03/07 |
|
151+ Benefit Program Application |
#MGA-10-1-UNI HCSC
|
10/10 |
|
Addendum to the Insured BPA Regarding Affiliated Companies (Word Doc) |
#MGA-10-1-ADD
|
2007 |
|
BlueCare® Dental HMO Benefit Program Application |
#GA-10-3 HCSC
|
10/10 |
|
Dental Claim Form |
#20350
|
01/12 |
|
Disabled Dependent Authorization Form (for Group Plans) | #238412.0819 | 08/19
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Enrollment Change Request Form | #22735 | 06/10 |