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Blue Access for Employers

Community Participating Option for 151+ Employees

Community Participating Option
 

Form Name

Form Number

Date
Employer Enrollment
  General Notice of Special Enrollment Rights  

#22963

04/15
  Notice of Information Practices 

#EB4644

03/04
  Standard Authorization Form and other HIPAA Privacy Forms

 N/A

04/18
  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
  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
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

11/03
  Medical Claim Form (Domestic) 

228934.1015

10/15
  Medical Claim Form (International) 

N-120-420

 
  COBRA Election Form     
  COBRA Notification Form     
  IL Employee Continuation Privilege Election Form  #24056 02/12
  IL Continuation Group Request From  #24044 02/12