Blue Access for Employers

Community Participating Option for 151+ Employees

Community Participating Option
 

Form Name

Form Number

Date

Employer Enrollment
  General Notice of Special Enrollment Rights  

#22963

04/15

  Notice of Information Practices 

#EB4644

03/04

  Standard Authorization Form and other HIPAA Privacy Forms

 N/A

04/18

  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

  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

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

11/03

  Medical Claim Form (Domestic) 

228934.1015

10/15

  Medical Claim Form (International) 

N-120-420

 

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