Blue Access for Employers

Downloadable Forms for 2-50 Employees

BlueCare Dental - PPO
 

Form Name

Form Number

Date

For Dental Only 
  Dental Claim Form  

#20350

01/12

For BAE/Dental 
  2017 Benefit Program Application (BPA)  

#IL-SG-HP-BPA

05/16

  Employer Group Information Form (new group)  

#IL Small Group EGI

01/16

  Enrollment Change Request Form  

#22735

06/10

  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

  Small Group Benefit Plan Selection Form  
for accounts effective 1/1/17 and after

#GA-RSG 2017-BPS

09/16

  Small Group Benefit Plan Selection Form  
for accounts effective 1/1/17 and after

#GA-RSG 2017-BPS

09/16

  Small Group Benefit Plan Selection Form  
for accounts effective 1/1/16 and after

#GA-RSG 2016-BPS

11/15

  Small Group Benefit Plan Selection Form  
for accounts effective 1/1/16 and after

#GA-RSG 2016-BPS

11/15

  Small Group Benefit Plan Selection Form  
for accounts effective 1/1/15 and after

#GA-RSG 2015-BPS

11/14

  Small Group Benefit Plan Selection Form  
for accounts effective 1/1/15 and after

#GA-RSG 2015-BPS

11/14

  Small Group Benefit Plan Selection Form  
for accounts effective 1/1/13 and after

#GA-10-9-SMGRP BPSF

01/13

  Small Group Benefit Plan Selection Form  
for accounts effective 7/1/12 and after

#GA-10-9-SMGRP BPSF

07/12

 

Benefit Program Application 

#IL-SG-HP-BPA

05/15

  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 Regulated  

#227019

09/14

  Dental Claim Form  

#20350

01/12

  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

  AD Change Form  

 

11/14