Blue Access for Producers

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Temporary Medical Coverage
Title & Form Number
SelecTEMP PPO Application - 31323
SelecTEMP PPO Outline of Coverage - 30283
SelecTEMP PPO Flier - 31939
Individual/Family Products
Title & Form Number
BCBSIL Individual Coverage Plan Selection - 31938
Under 65 Major Medical Individual Application (includes BCBSIL Individual Coverage Plan Selection Form # 31938 + IL Standard Application Form # 32077)
Product Guide - 31735
Individual/Family Rate Book - 31736
BlueEdge Individual HSA Outline of Coverage - 31532
Under 65 Sales Guide - 31741
Product Comparison Chart - 31737
SelectBlue Outline of Coverage - 31243
SelectBlue Advantage Outline of Coverage - 30133
BlueValue Outline of Coverage - 31242
BlueValue Advantage Outline of Coverage - 30134
BlueChoice Select Outline of Coverage - 30131
BlueChoice Value Outline of Coverage - 30132
BlueCare Dental PPO
Title & Form Number
Dental BlueCare PPO Outline of Coverage - 31440
General Supplies
Title & Form Number
Conditional Receipt Form - 31810
EZ Blue Form - 31561
PPO Hospital Listing (Under 65) - 30101
BlueChoice Hospital Listing - 30170
Claim Form (all Series II & III Products) - 01103
Standard Authorization Form to Use/Disclose Protected Health Information (PHI) - 31160
Producer Guide to List Bill - 32388
Guide to List Bill for Employers - 32387
List Bill Transmittal - 32389
Personal Health Insurance Certification for Employers - 30290
Personal Health Insurance Certification for Employees - 30291
Series II Application for Change in Coverage - 31370
Series III Application for Change in Coverage - 31371
*Please print or download brochure - available online only

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