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Blue Access for Employers

BluePrint for 151+ Employees

BluePrint

Form Name

Form Number

Date
Employer Enrollment
General Notice of Special Enrollment Rights   

#22963

04/15
Standard Authorization Form and other HIPAA Privacy Forms

N/A

08/15
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  

#20910

09/12
Benefit Program Application Form 

#IL-LG-BPR-HP-BPA

05/15
Addendum to the Insured BPA Regarding Affiliated Companies 

#MGA-10-1-ADD

2007
151+ Employee Application & Policy Change Form 

#20005

11/14
151+ Employee Application & Policy Change Form - Spanish 

#228157

11/14
Medicare Secondary Payer (MSP) Employer Acknowledgement Form with Instructions  

#240208.0320

03/20
Information Regarding Medicare Secondary Payer (MSP) Statute  

#21091.0609

06/09
MSP Fact Sheet (380 kb)  

#24443.0612

06/12
Individual Medicare Secondary Payer Form  

#20473

10/04
Health Care Account (HCA) ASO Benefit Program Application  

 

08/11
Account Maintenance and Supply Forms
Group Administrator's Member Transaction Form  

 #20406

06/10
Student Certification Form  

#23402.0611

06/11
Dependent Student Medical Leave Certification Form  

 #23077.0111

01/11
Disabled Dependent Authorization Form (for Group Plans) 

 #238412.0819

08/19
Enrollment Change Request Form  

#22735

06/10
Medical Claim Form (Domestic) 

228934.1015

10/15
Medical Claim Form (International)   

N-120-420

 
COBRA Election Form  

 

  
COBRA Notification Form  

 

  
Employee Continuation Privilege Election Form  #24056  
Continuation Group Request Form  #24044