Downloadable Forms for 51-150 Employees

BluePrint
	Form Name	Form Number	Date
Proposal
	Request for BluePrint Intermediate Proposal Form		08/14
Employer Enrollment
	Employer Group Information Form (new group)	#IL Small Group EGI	01/16
	Submission Guidelines for Small Group Health Coverage	#23162	02/11
	HMO/CPO Provider Selection Enrollment and Change Form	#22840	01/11
	Producer/Employer Tips for Submitting New Small Groups Flier	#22018	06/09
	Benefit Program Application (BPA) for accounts effective 1/1/2020 and after	#IL-LG-51-150-HP-BPA	06/19
	Benefit Program Application (BPA) for accounts effective 1/1/2020 and after	#IL-LG-51-150-HP-BPA	06/19
	Benefit Plan Section (BPS) Form for accounts effective 1/1/2020 and after	#GA-10-9-SMGRP BPSF HCSC MM	02/20
	Benefit Plan Section (BPS) Form for accounts effective 1/1/2020 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
	Small Group HCSC/FDL Disclosure Form	#EB4644	07/01
	Medicare Secondary Payer (MSP) Employer Acknowledgement Form with Instructions	#240208.0320	03/20
	Information Regarding the 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) Benefit Program Application	#GA-10-4-HCA SG	12/04
Account Maintenance and Supply Forms
	Group Administrator's Member Transaction Form	#20406	06/10
	Student Certification Form	#23402.0611	06/11
	Student Dependent Medical Leave Certification Form	#23077.0111	01/11
	Disabled Dependent Authorization Form (for Group Plans) – Members with an employer-sponsored health plan should use this form to request continuation of coverage on their existing policy for a dependent who is incapable of self-support because of mental or physical impairment. Mail or fax the completed form to BCBSIL (see address and fax number at the top of the form). You can also use this form to add a disabled dependent to a new policy (include this completed form when you submit your enrollment application).	#238412.0819	08/19
	Enrollment Change Request Form	#22735	06/10
	Medical Claim Form (Domestic)	228934.1015	10/15
	Medical Claim Form (International)	N-12-420
	COBRA Election Form
	COBRA Notification Form
	IL Employee Continuation Privilege Election Form	#24056	02/12
	IL Continuation Group Request From	#24044	02/12