Blue Access for Producers

Downloadable Forms for 51-150 Employees


BlueCare Dental - PPO


Form Name Form Number Date

Employer Enrollment

Benefit Plan Selection Form 
(For Accounts Effective 1/1/14 and after)
#GA-10-9-SMGRP BPSF 01/14
Benefit Plan Selection Form 
(For Accounts Effective 1/1/14 and after)
#GA-10-9-SMGRP BPSF 01/14
Benefit Plan Selection Form 
(For Accounts Effective 7/1/12 and after)
#GA-10-9-SMGRP BPSF 07/12
Benefit Plan Selection Form 
(For Accounts Effective 8/1/11 and after)
#GA-10-9-SMGRP BPSF 08/11
Benefit Program Application Form 
(For Accounts Effective 1/1/14 and after)
#IL-LG-51-150-HP-BPA 01/14
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

Addendum to the Insured BPA Regarding Affiliated Companies  #MGA-10-1-ADD 2007
General Notice of Special Enrollment Rights and Preexisting Condition Exclusion  #225425 09/13

Account Maintenance Forms

Group Administrator's Member Transactions Form  #20406 06/10
Dental Claim Form  #20350 01/12