Blue Access for Employers

BluePrint for 151+ Employees

BluePrint

Form Name

Form Number

Date

Employer Enrollment
General Notice of Special Enrollment Rights   

#22963

04/15

Standard Authorization Form and other HIPAA Privacy Forms

N/A

08/15

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  

#20910

09/12

Benefit Program Application Form 

#IL-LG-BPR-HP-BPA

05/15

Addendum to the Insured BPA Regarding Affiliated Companies 

#MGA-10-1-ADD

2007

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

Health Care Account (HCA) ASO Benefit Program Application  

 

08/11

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

Enrollment Change Request Form  

#22735

06/10

Medical Claim Form (Domestic) 

228934.1015

10/15

Medical Claim Form (International)   

N-120-420

 

COBRA Election Form  

 

 
COBRA Notification Form  

 

 
Employee Continuation Privilege Election Form  #24056  
Continuation Group Request Form  #24044