Blue Access for Employers

Downloadable Forms for 151+ Employees

ASO

Form Name

Form Number

Date

Employer Enrollment
ASO Benefit Program Application  

#HCSC IL GEN ASO BPA

01/14

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  

#21122.0913

09/13

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

Enrollment Change Request Form  

#22735

06/10

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

Medical Claim Form (Domestic)  – Members should use this form to request reimbursement for health care services obtained within the United States, a U.S. territory, when on a cruise ship, or on a U.S. military base.

228934.1015

10/15

Medical Claim Form (Domestic) – Spanish 

229421.0116

01/16

Medical Claim Form (International)  – Members should use this claim form to request reimbursement for health care services obtained when traveling internationally – when outside of the United States or a U.S. territory, but NOT for services obtained on a cruise ship or a U.S. military base.

16-581-N35

 
Medical Claim Form (International) – Spanish 

16-581-N35

 
COBRA Election Form       
COBRA Notification Form