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Individual Forms and Medicare Forms

Here are some commonly used forms for conducting business with Blue Cross and Blue Shield of Illinois (BCBSIL).

The forms below are available as PDF files. You will need the Adobe® Reader® to view the PDFs. Download this software free of charge at Adobe's site .

To complete a form, just click on the appropriate link, print it, and then fill it out and mail it in.

2014 Individual Forms

Stock # / Date

Enrollment/Change Forms

Illinois Form #

32635.0313

Health Application/Change in Coverage

APP-IND-2014

225331.0813

Health Application/Change in Coverage (Spanish Version)

APP-IND-2014-SP

31323.0812 IL

SelecTEMP PPO Application

N/A

475322.0813

SelecTEMP PPO Application (Spanish Version)

N/A

22500.0613

Dental Application/Change in Coverage

APP-DENT-IND-2014

225332.0813

Dental Application / Change in Coverage (Spanish Version)

APP-DENT-IND-2014

Stock # / Date

Outline of Coverage Forms

Illinois Form #

N/A

Blue Security PPO 010

IL-I-P-CA-OF.OOC-010FR

N/A

Blue PPO Bronze 005

IL-I-P-OF.OOC-BR-005FR

N/A

Blue PPO Bronze 006

IL-I-P-OF.OOC-BR-006FR

N/A

Blue PPO Silver 004

IL-I-P-OF.OOC-SL-004FR

N/A

Blue PPO Silver 003

IL-I-P-OF.OOC-SL-003FR

N/A

Blue PPO Gold 012

IL-I-P-OF.OOC-GD-012FR

N/A

Blue PPO Gold 002

IL-I-P-OF.OOC-GD-002FR

N/A

Blue PPO Gold 001

IL-I-P-OF.OOC-GD-001FR

N/A

Blue Choice Bronze PPO 005

IL-I-B-OF.OOC-BR-005FR

N/A

Blue Choice Bronze PPO 006

IL-I-B-OF.OOC-BR-006FR

N/A

Blue Choice Silver PPO 004

IL-I-B-OF.OOC-SL-004FR

N/A

Blue Choice Silver PPO 003

IL-I-B-OF.OOC-SL-003FR

N/A

Blue Choice Gold PPO 007

IL-I-B-OF.OOC-GD-007FR

N/A

Blue Choice Gold PPO 002

IL-I-B-OF.OOC-GD-002FR

N/A

Blue Choice Gold PPO 001

IL-I-B-OF.OOC-GD-001FR

N/A

Blue Precision Platinum HMO 004

IL-I-H-OF.OOC-PL-004FR

N/A

Blue Precision Gold HMO 001

IL-I-H-OF.OOC-GD-001FR

N/A

Blue Precision Silver HMO 002

IL-I-H-OF.OOC-SL-002FR

N/A

Blue Precision Bronze HMO 003

IL-I-H-OF.OOC-BR-003FR

Stock # / Date

Miscellaneous Forms

Illinois Form #

31561.0713

Automated Premium Payment Authorization Agreement

N/A

225975.0114

Automated Premium Payment Authorization Agreement (Spanish Version)

N/A

32389.0913

List Bill Agreement

N/A

Stock # / Date

Other Benefit/Plan Information

Illinois Form #

225308.0214

Sales Brochure

N/A

225495.0214

Sales Brochure (Spanish Version)

N/A

31939.0213

SelecTEMP PPO Flier

N/A

225341.1013

SelecTEMP PPO Flier (Spanish Version)

N/A

37265.0613

Platinum Plan Comparison Chart (Off Exchange)

N/A

32764.0613

Gold Plan Comparison Chart (Off Exchange)

N/A

32769.0613

Gold Plan Comparison Chart (On Exchange)

N/A

32763.0613

Silver Plan Comparison Chart (Off Exchange)

N/A

32768.0613

Silver Plan Comparison Chart (On Exchange)

N/A

32762.0613

Bronze Plan Comparison Chart (Off Exchange)

N/A

32767.0613

Bronze Plan Comparison Chart (On Exchange)

N/A

225626.1013

Multi-State Plan (MSP) Comparison Chart (On Exchange)

N/A

225791.1113

Multi-State Plan (MSP) Comparison Chart (On Exchange) (Spanish Version)

N/A

Stock # / Date

Dental Plan/Benefit Information

Illinois Form #

225309.1013

BlueCare Dental Flier 

N/A

225632.1013

BlueCare Dental Flier (Spanish Version) 

N/A

73740.0513

BlueCare Dental 4 Kids 1B 

IL-IN-D-OOC-4K-99

N/A

BlueCare Dental 4 Kids 1A 

IL-IN-D-OOC-4K-98

N/A

BlueCare Dental 1A 

IL-IN-D-OOC-04

N/A

BlueCare Dental 1B 

IL-IN-D-OOC-05

Stock # / Date

Medicare Supplement Forms and Documents

Illinois Form #

32126.1012

Medicare Supplement Application

IL-MS-APP-2011

31812.0311

Application for Medicare Supplement Plan Changes

IL-065-Change App

31547.0314 IL

Medicare Supplement Outline of Coverage – METRO Combo (Effective March 1, 2014)

MCOMOOC

31549.0314 IL

Medicare Supplement Outline of Coverage – STATE Combo (Effective March 1, 2014)

SCOMOOC

31548.0314 IL

Medicare Supplement Outline of Coverage – STATE (Effective March 1, 2014)

SSTDOOC

31752.0311

Medicare Supplement Payment Option Authorization

N/A

32351.0712

Medicare Supplement List Bill

N/A

23648.0911

Medicare Supplement Notice of Replacement

IL-MS-NOR-2011

31601.0114 IL

Policy Checklist (All Plans, Except Plan K & L)

APCKLIST

30346.0114 IL

Policy Checklist (Plans K & L)

KLCKLIST

N/A

Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare

N/A

32101.0113

Medicare Supplement Sales Brochure - STATE

N/A

30235.0812 IL

Medicare Supplement Product Guide

N/A

30189.0213 IL

Medicare Select Hospital Listing

N/A

N/A

Standard Authorization Form and other HIPAA Privacy Forms

N/A

Pre-2014 and Pre-ACA Individual Forms and Documents

Stock # / Date

Individual Enrollment Forms, Plan Selection Forms and Change Forms

Illinois Form #

32077.0713

Under 65 Major Medical Individual Application – This form includes the BCBSIL Individual Coverage Plan Selection form (31938).

70670

31938.0713 IL

BCBSIL Individual Coverage Plan Selection

APSUPPINFO-2

31323.0812 IL

SelecTEMP PPO Application

N/A

31370.0713

Series II Application for Change in Coverage

N/A

31371.0713

Series III Application for Change in Coverage

S3CHAPP

Stock # / Date

Individual Outlines of Coverage

Illinois Form #

31532.0713 IL

BlueEdge Individual HSA Outline of Coverage

HSAOOC0313

31242.0713 IL

BlueValue Outline of Coverage

BVOOC0910

30134.0713 IL

BlueValue Advantage Outline of Coverage

BVAOOC0910

30131.0713 IL

BlueChoice Select Outline of Coverage

BCSOOC0910

30132.0713 IL

BlueChoice Value Outline of Coverage

BCVOOC0910

31243.0713 IL

SelectBlue Outline of Coverage

SBOOC0910

30133.0713 IL

SelectBlue Advantage Outline of Coverage

SBAOOC0910

30283.0812 IL

SelecTEMP PPO Outline of Coverage

STOOC0812

02928.0711 IL

BlueChoice Pathway Outline of Coverage

BCPOOC0711

02927.0711 IL

Blue Pathway Outline of Coverage

BPOOC0711

31440.0113 IL

BlueCare Dental PPO Outline of Coverage

OOC-IND DENTAL REV3

Stock # / Date

Individual Claim Forms and Order Forms

Illinois Form #

20157.0112

Prescription Drug Claim Form
Members with pharmacy benefits through an individual insurance plan can use this form to request reimbursement for a prescription drug purchase. The original pharmacy receipt must be submitted with the completed form to Prime Therapeutics, the pharmacy benefits manager.

3272 IL

01103.1209

Medical Claim Form (all Series II & III Products)
Members should use this form to request reimbursement of health services not already filed by their doctor or hospital

N/A

N-12-420

BlueCard Worldwide® International Claim Form
Members should use this form to request reimbursement for out-of-network services received when traveling internationally (outside of U.S.).

N/A

3208 NM NEW

PrimeMail New Prescription Order Form
Members with prescription drug coverage can use this form to mail order new prescription maintenance medication. The completed form should be mailed to PrimeMail, along with the original prescription signed by the prescribing doctor.

N/A

3208 NM REFILL

PrimeMail Refill Prescription Order Form
Members with prescription drug coverage can use this form to mail order refills for prescribed maintenance medication.

N/A

Stock # / Date

Individual Miscellaneous Forms

Illinois Form #

31810.0210 IL

Conditional Receipt Form

N/A

31561.0112

EZ Blue Form - This form is to be used for pre-ACA plans only.

N/A

32389.0712

List Bill Transmittal

N/A

Stock # / Date

Individual Other Plan Information

Illinois Form #

32388.0712

Producer Guide to List Bill

N/A

32387.0712

Guide to List Bill for Employers

N/A

31737.0713

Plan Comparison Chart

N/A

31741.0713 IL

Under 65 Sales Guide

N/A

32107.0211

Submission Guidelines for Individual & Family Health Coverage

N/A

32092.0412

Blue Pathway Flier

N/A

31939.0213

SelecTEMP PPO Flier

N/A

N/A

Standard Authorization Form and other HIPAA Privacy Forms

N/A

Other Medicare Products

Thank you for your interest in Medicare products offered by BCBSIL. Please remember that before producers can market other Medicare products (e.g., Part D, Medicare Advantage) and order and/or download marketing materials, they must complete our training and certification/re-certification program . Please contact us for more information.