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Blue Access for Producers

Downloadable Forms for 151+ Employees


BluePrint

 

Form Name Form Number Date

Employer Enrollment
BluePrint Benefit Program Application Form  #GA-10-9-BPR-AF
HCSC		 09/12
Health Care (HCA) Plan Benefit Program Application 
(Applicable to 151+ Accounts)		 #GA-10-4 HCA LG 12/04
Health Care (HCA) Plan Benefit Program Application 
(Applicable to 51-150 Insured Group Accounts)		 #GA-10-4 HCS SG 08/11
Health Care (HCA) Plan Benefit Program Application    08/11
Addendum to the Insured BPA Regarding Affiliated Companies  #MGA-10-1-ADD 2007
151+ Employee Application & Policy Change Form (HCSC Privacy Notice)  #20005 05/10
Medicare Secondary Payer (MSP) Employer Acknowledgement Form with Instructions  #21122.0111 01/11
Information Regarding Medicare Secondary Payer (MSP) Statute  #21091.0609 06/09
MSP Fact Sheet  

#24443.0612

06/12
Individual Medicare Secondary Payer Form  #20473 10/04
Disclosure Notice  #EB4644 03/04
General Notice of Special Enrollment Rights and Preexisting Condition Exclusion  #22963 09/11
Affidavit of Domestic Partnership  #20551 01/05

Account Maintenance and Supply Forms
Group Administrator's Member Transactions Form  #20406 06/10
Enrollment Change Request Form  #22735 06/10
Medical Claim Form  #20479 06/07
International Claim Form  #N35-10-118  
COBRA Election Form     
COBRA Notification Form     
IL Employee Continuation Privilege Election Form  #24056 02/12
IL Continuation Group Request From  #24044 02/12
Student Certification Form  #23402.0611 06/11
Dependent Student Medical Leave Certification Form  #23077.0111 01/11
Statement of Termination of Domestic Partnership  #20560 02/07
Tax Information on Health Benefits for Domestic Partnership  #20559 02/07