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Blue Access for Employers

Downloadable Forms for 2-50 Employees

BlueCare Dental — HMO
 

Form Name

Form Number

Date
  2017 Benefit Program Application (BPA)  

#IL-SG-HP-BPA

05/16
  Employer Group Information Form (new group)  

#IL Small Group EGI

01/16
  Small Group Benefit Plan Selection Form  
for accounts effective 1/1/17 and after

#GA-RSG 2017-BPS

09/16
  Small Group Benefit Plan Selection Form  
for accounts effective 1/1/17 and after

#GA-RSG 2017-BPS

09/16
  Small Group Benefit Plan Selection Form  
for accounts effective 1/1/16 and after

#GA-RSG 2016-BPS

11/15
  Small Group Benefit Plan Selection Form  
for accounts effective 1/1/16 and after

#GA-RSG 2016-BPS

11/15
  Small Group Benefit Plan Selection Form  
for accounts effective 1/1/15 and after

#GA-RSG 2015-BPS

11/14
  Small Group Benefit Plan Selection Form  
for accounts effective 1/1/15 and after

#GA-RSG 2015-BPS

11/14
  Small Group Benefit Plan Selection Form  
for accounts effective 1/1/15 and after

#GA-10-9-SMGRP BPSF

11/13
  Small Group Benefit Plan Selection Form  
for accounts effective 7/1/12 and after

#GA-10-9-SMGRP BPSF

07/12
 

Benefit Program Application Form 

#IL-SG-HP-BPA

05/15
  BlueCare® Dental HMO Benefit Program Application  

#GA-10-3 HCSC

10/10
  Addendum to the Insured BPA Regarding Affiliated Companies 

#MGA-10-1-ADD

2007
  Dental Claim Form  

#20350

01/12
  Enrollment Change Request Form  

#22735

06/10
For BAE/Dental
  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
  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 Regulated  

#227019

09/14
  Disabled Dependent Authorization Form (for Group Plans)  

#238412.0819

08/19
  AD Change Form  

 

11/14
  Enrollment Change Request Form  

#22735

06/10