Blue Access for Employers

Downloadable Forms for 151+ Employees

BlueCare Dental — PPO
 
Form Name
Form Number
Date

Employer Enrollment

  General Notice of Special Enrollment Rights  

#22963

04/15

  HIPAA Notice of Privacy Practices

 

 

  Standard Authorization Form and other HIPAA Privacy Forms

 

 

  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

  Employer New Business Checklist  
#20910

03/07

  BluePrint Benefit Program Application Form (BPA)  
#GA-10-9-BPR-AF-HCSC

09/12

  Addendum to the Insured BPA Regarding Affiliated Companies (Word Doc) 
#MGA-10-1-ADD

2007

  ASO Benefit Program Application (BPA) Form  
#GA-10-4-HCSC

02/04

  100 Plus Insured Accounts Benefit Program Application (BPA) Form 
#MGA-10-1 UNI HCSC

10/10

  Enrollment Change Request Form 
#22735

06/10

Account Maintenance Forms

 

Dental Claim Form  

#20350

01/12

  Disabled Dependent Authorization Form (for Group Plans) 

#238412.0819

08/19