Downloadable Forms for Mid-Market Group Products (Groups of 51-150)

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
2024 Enrollment Package – Includes Benefit Program Application (BPA), Benefit Plan Selection (BPS) Form, EGI Form and Artifacts Documentation for new accounts effective 1/1/2024 sign now N/A
2024 Benefit Program Application (BPA) – For new accounts effective 1/1/2024 and after sign now download form Word Document
download form
2023 Enrollment Package – Includes Benefit Program Application (BPA), Benefit Plan Selection (BPS) Form, EGI Form, and Artifacts Documentation for new accounts effective 7/1/23 sign now N/A
2023 Benefit Program Application (BPA) – For new accounts effective 1/1/23 and after sign now download form Word Documentdownload form
Employer Group Information (EGI) Form – This form must be submitted with the BPA sign now  download form
Affidavit of Domestic Partnership sign now download form
Affordable Care Act (ACA) Small Group New Business Checklist N/A download form
Full-Time Status Certification for Owners, Partners, Proprietors sign now download form Word Document
download form
General Notice of Special Enrollment Rights N/A download notice
HMO/CPO Provider Selection Enrollment and Change Form 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

 

 

Renewal Forms and Information

Form Name Digital Form Download
2023–2024 Important Benefit Changes/Uniform Modification Notice - Identifies some of the most important benefit plan changes for the 2023–2024 coverage year. N/A download notice
2024 Benefit Plan Selection (BPS) Form – For new accounts effective 1/1/2024 and after sign now download form Word Document
download form
2023 Benefit Plan Selection (BPS) Form – For new accounts effective 7/1/2023 and after sign now download form Word Document
download form
Addendum to the Insured BPA Regarding Affiliated Companies sign now download form Word Document
Medical Loss Ratio (MLR) Written Assurance Form- Complete this standalone form only for an existing group if one of these conditions applies: 1) the group is changing Church designation as defined by the IRS, or 2) it is a Church group wanting to change how the rebate is handled. sign now download form
Average Employee Count (AEC) Form sign now download form

 

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
Submission Guidelines for Small Group Health Coverage N/A download flier
General Notice of Special Enrollment Rights N/A download notice  

 

BlueCare HMO 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
Submission Guidelines for Small Group Health Coverage N/A download flier
General Notice of Special Enrollment Rights N/A download notice

 

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 claim form to request reimbursement for purchasing a prescription drug or over-the-counter (OTC) COVID-19 diagnostic home test kit. They must submit the pharmacy counter receipt with the completed form. Cash register receipts for OTC COVID-19 test kits may not be accepted. Not all plans cover OTC COVID-19 home test kits. If the member's plan does not cover, they will not be reimbursed. 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 sign now download form
Individual MSP Form N/A download form
Information Regarding MSP Statute N/A download flier
MSP Fact Sheet N/A download fact sheet

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 Pharmacy) – For HMO Group and Individual Plans N/A download form
Prescription Drug Mail-Order Form (AllianceRx Walgreens Pharmacy) – 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

 

Miscellaneous Forms

Form Name Digital Form Download
Small Group HCSC/FDL Disclosure Form N/A download form
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
Dependent Student Medical Leave Certification Form 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