Downloadable Forms for Large Group Products (Groups of 151+)

New Business/Enrollment Forms

Form Name Digital Form Download
Group Enrollment Application/Change Form – Use this form to apply for group coverage or to make changes to an existing BCBSIL policy N/A download form
Group Enrollment Application/Change Form – Spanish N/A download form
Affidavit of Domestic Partnership sign now download form
Full-Time Status Certification for Owners, Partners, Proprietors sign now download form Word Document
General Notice of Special Enrollment Rights N/A download form
Smart Census Import Tool
(To obtain the latest Version of the tool, please log into Blue Access for Producers.)
N/A N/A
Underwriting Reference Guide for Brokers N/A download guide  

 

BlueCare PPO Dental Forms

Form Name Digital Form Download
Group Enrollment Application/Change Form – Use this form to apply for group coverage or to make changes to an existing BCBSIL policy N/A download form
Group Enrollment Application/Change Form – Spanish N/A download form
General Notice of Special Enrollment Rights N/A download form  

BlueCare HMO Dental Forms

Form Name Digital Form Download
2021 Group Enrollment Application/Change Form – Use this form to apply for group coverage effective 1/1/2021, or to make changes to an existing BCBSIL policy N/A download form
2021 Group Enrollment Application/Change Form – Spanish N/A download form
General Notice of Special Enrollment Rights N/A download form

Claim Forms

Form Name Digital Form Download
Dental Claim Form – Members should use this form to file dental claims for reimbursement that are not filed by their dental provider. N/A download form
Dental Claim Form – Spanish N/A download form
Medical Claim Form (Domestic) – Members should use this form to request reimbursement for health care services obtained within the United States, a U.S. territory, when on a cruise ship, or on a U.S. military base. N/A download form
Medical Claim Form (Domestic) – Spanish N/A download form
Medical Claim Form (International) – Members should use this claim form to request reimbursement for health care services obtained when traveling internationally – when outside of the United States or a U.S. territory, but NOT for services obtained on a cruise ship or a U.S. military base. N/A download form
Medical Claim Form (International) – Spanish N/A download form
Prescription Drug Claim Form (Prime Therapeutics) – Members with pharmacy benefits through BCBSIL can use this Prime Therapeutics claim form to request reimbursement for purchasing a prescription drug or over-the-counter (OTC) COVID-19 diagnostic home test kit. For prescription drugs, you must submit the original pharmacy receipt with the completed form. For COVID-19 home test kits, you must submit the original cash register or online receipt with the completed form. N/A download form
Prescription Drug Claim Form (Prime Therapeutics) – Spanish N/A download form

 

Medicare Secondary Payer (MSP) Forms and Information

Form Name Digital Form Download
Annual MSP Employer Acknowledgement Form (EAF) with Instructions N/A download form
Information Regarding MSP Statute N/A download form
MSP Fact Sheet N/A download form

Prescription Drug Forms

Form Name Digital Form Download
Prescription Drug Claim Form (Prime Therapeutics) N/A download form
Prescription Drug Claim Form (Prime Therapeutics) – Spanish N/A download form
Prescription Drug Mail-Order Form (AllianceRx Walgreens Prime) – For HMO Group Plans and Individual Plans N/A download form
Prescription Drug Mail-Order Form (AllianceRx Walgreens Prime) – Spanish N/A download form
Prescription Drug Mail-Order Form (Express Scripts) – For PPO and HMO Group Plans and Individual Plans N/A download form
Prescription Drug Mail-Order Form (Express Scripts) – Spanish N/A download form
Women's Contraceptive Coverage List N/A download list

Miscellaneous Forms

Form Name Digital Form Download
Membership Change Request Form N/A download form
IL Employee Continuation Privilege Election Form N/A download form
IL Continuation Group Request Form N/A download form
Statement of Termination of Domestic Partnership N/A download form
Tax Information on Health Benefits for Domestic Partnership N/A download form
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). N/A download form
Producer of Record Transfer Form and Instructions N/A download form

Legal / HIPAA Forms

Form Name Digital Form Download
Standard Authorization Form and other HIPAA Privacy Forms N/A N/A