Blue Access for Employers

HMO Illinois for 151+ Employees

HMO Illinois
 
Form Name
Form Number
Employer Enrollment
  General Notice of Special Enrollment Rights   

#22963

  Notice of Information Practices  

#EB4644

  Standard Authorization Form and other HIPAA Privacy Forms

N/A

  Affidavit of Domestic Partnership  

#20551

  Statement of Termination of Domestic Partnership  

#20560

  Tax Information on Health Benefits for Domestic Partnership  

#20559

  Employer New Business Checklist  
#20910
  HMOI/BlueAdvantage BPA 
#IL-LG-151PLUS-H-BPA
  Addendum to the Insured BPA Regarding Affiliated Companies 
#MGA-10-1-ADD
  151+ Employee Application & Policy Change Form 
#20005.1114
  151+ Employee Application & Policy Change Form - Spanish   
#228157.1114
  Medicare Secondary Payer (MSP) Employer Acknowledgement Form with Instructions  
#21122.0913
  Information Regarding Medicare Secondary Payer (MSP) Statute  
#21091.0609
  MSP Fact Sheet (380 kb)  

#24443.0612

  Individual Medicare Secondary Payer Form  
#20473
  Group Administrator's Member Transaction Form  

#20406

  Student Certification Form   #23402.0611
  Dependent Student Medical Leave Certification Form   #23077.0111
  Disabled Dependent Authorization Form (for Group Plans) 

#238412.0819

  COBRA Election Form    
  COBRA Notification Form    
  IL Employee Continuation Privilege Election Form   #24056
  IL Continuation Group Request From   #24044
  Medical Claim Form (Domestic) 
228934.1015
  Medical Claim Form (International)  
N-120-420
  Enrollment Change Request Form  
#22735