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Blue Access for Employers

Downloadable Forms for 51-150 Employees

BlueCare Dental — HMO
 

Form Name

Form Number

Date
  Employer Group Information Form (new group)  

#IL Small Group EGI

01/16
  Submission Guidelines for Small Group Health Coverage  

#23162

02/11
  Small Group Standard Health Application  

#22997, #23071

12/11, 01/11
  HMO/CPO Provider Selection Enrollment and Change Form  

#22840

01/11
  Enrollment Change Request Form  

#22735

06/10
  Benefit Plan Selection (BPS) Form  
for accounts effective 1/1/20 and after

#GA-10-9-SMGRP BPSF HCSC MM

02/20
  Benefit Plan Selection (BPS) Form  
for accounts effective 1/1/20 and after

#GA-10-9-SMGRP BPSF HCSC MM

02/20
  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
  New Business Checklist for SG Non-Regulated  

#227020

09/14
  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