Blue Access for Employers

Downloadable Forms for 51-150 Employees

BluePrint

 

Form Name

Form Number

Date

Proposal
  Request for BluePrint Intermediate Proposal Form  

 

08/14

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

  Producer/Employer Tips for Submitting New Small Groups Flier  

#22018

06/09

  Benefit Program Application (BPA)  
for accounts effective 1/1/2020 and after

#IL-LG-51-150-HP-BPA

06/19

  Benefit Program Application (BPA)  
for accounts effective 1/1/2020 and after

#IL-LG-51-150-HP-BPA

06/19

  Benefit Plan Section (BPS) Form  
for accounts effective 1/1/2020 and after

#GA-10-9-SMGRP BPSF HCSC MM

02/20

  Benefit Plan Section (BPS) Form  
for accounts effective 1/1/2020 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

  Small Group HCSC/FDL Disclosure Form  

#EB4644

07/01

  Medicare Secondary Payer (MSP) Employer Acknowledgement Form with Instructions  

#21122.0913

09/13

  Information Regarding the 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) Benefit Program Application   

#GA-10-4-HCA SG

12/04

Account Maintenance and Supply Forms
  Group Administrator's Member Transaction Form  

 #20406

06/10

  Student Certification Form  

 #23402.0611

06/11

  Student Dependent 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

  Enrollment Change Request Form  

#22735

06/10

  Medical Claim Form (Domestic) 

228934.1015

10/15

  Medical Claim Form (International)  

N-12-420

 

  COBRA Election Form  

 

 
  COBRA Notification Form  

 

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