Blue Access for Employers

Downloadable Forms for 51-150 Employees

BlueCare Dental — PPO

 

Form Name

Form Number

Date

Employer Enrollment
  Employer Group Information Form (new group)  

#IL Small Group EGI

01/16

  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

  Enrollment Change Request Form  

#22735

06/10

  Benefit Plan Section (BPS) Form  
for accounts effective 1/1/20 and after

#GA-10-9-SMGRP BPSF HCSC MM

02/20

  Benefit Plan Selection (BPS) Form  
for accounts effective 1/1/20 and after

#GA-10-9-SMGRP BPSF HCSC MM

02/20

  General Notice of Special Enrollment Rights  

#22963

04/15

  Notice of Information Practices  

#EB4644

03/04

  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

  New Business Checklist for SG Non-Regulated  

#227020

09/14

Account Maintenance Forms
  Dental Claim Form  

#20350

01/12

  Disabled Dependent Authorization Form (for Group Plans)  

#238412.0819

08/19