Blue Access for Employers

Downloadable Forms for 2-50 Employees

BlueAdvantage Entrepreneur
 

Form Name

Form Number

Date

Employer Enrollment
  2020 Benefit Program Application (BPA)  

#IL-SG-HP-BPA

05/19

  2020 Benefit Program Application (BPA)  

#IL-SG-HP-BPA

05/19

  2020 Benefit Program Selection (BPS) Form  

#GA-RSG 2020-BPS

10/19

  2020 Benefit Program Selection (BPS) Form  

#GA-RSG 2020-BPS

10/19

  Employer Group Information Form (small group)  

#IL Small Group EGI

02/16

  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

  General Notice of Special Enrollment Rights  

#22963

04/15

  Notice of Information Practices  

#EB4644

03/04

  HIPAA Privacy Practices Notice and Privacy Forms  

11/16

  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 Regulated  

#227019

09/14

  Small Group HCSC/FDL Disclosure Form  

#EB4644

07/01

  BAE Product Combination Options  

#20946

05/06

  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 (380 kb)  

#24443.0612

06/12

  Individual Medicare Secondary Payer Form  

#20473

10/04

  AD Change Form  

 

11/14

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)  – 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

  Producer Supply Requisition Form   

#OB3658

12/03

  Enrollment Change Request Form  

#22735

06/10

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