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

Here are some commonly used forms for conducting business with Blue Cross and Blue Shield of Illinois (BCBSIL). The forms provided in this section are applicable to groups with 151+ enrolled lives.

To access more downloadable forms, please log in to Blue Access for Producers. To review and sign your request now electronically, select the sign now option below. Or you can download and save the form, to review and sign at a later date.

New Business/Enrollment Forms for PPO/Non-HMO

Form Name Digital Form Download
Group Enrollment Application/Change Form – use this form to apply for group coverage or to make a change to an existing BCBSIL policy N/A download form
Group Enrollment Application/Change Form – Spanish N/A download form
Addendum to the Insured BPA Regarding Affiliated Companies sign now download form Word Document
Affidavit of Domestic Partnership sign now download form

Benefit Wallet® Benefits Design Guide for FSA, HRA and Commuter Spending Accounts – Submit an electronic copy of this form for each employer wishing to elect FSA and/or HRA integration with BenefitWallet.

 N/A download form

Consumer Directed Health Accounts Enrollment and Change Form – Use this form to collect employee FSA and/or HRA elections if sending enrollment through BCBSIL to BenefitWallet, HealthEquity or HSA Bank.

 N/A download form

Consumer Directed Health Accounts How-To Set Up Guide – Use this guide to learn details about setting up accounts that include HSA, FSA or HRA with vendor integration.

 N/A download guide

FSA Employer Setup Form – Flex – Submit an electronic copy of this form for each employer wishing to elect FSA and/or HRA integration with Flex.

 N/A download form
Full-Time Status Certification for Owners, Partners, Proprietors sign now download form Word Document
download form

HSA Employer Setup Form – Flex – Submit an electronic copy of this form for each employer wishing to elect HSA integration with Flex.

 N/A download form

HSA Employer Setup Form – Benefit Wallet® – Submit an electronic copy of this form for each employer wishing to elect HSA integration with BenefitWallet.

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HSA/FSA Employer Setup Form – HealthEquity® – Submit an electronic copy of this form for each employer wishing to elect HSA, FSA and/or HRA integration with HealthEquity.

 N/A download form

HSA/FSA Employer Setup Form – HSA Bank® – Submit an electronic copy of this form for each employer wishing to elect HSA, FSA and/or HRA integration with HSA Bank.

 N/A download form

 

New Business/Enrollment Forms for HMO (BlueAdvantage HMO and HMO Illinois)

Form Name Digital Form Download
Group Enrollment Application/Change Form – use this form to apply for group coverage or to make a change to an existing BCBSIL policy N/A download form
Group Enrollment Application/Change Form – Spanish N/A download form
Addendum to the Insured BPA Regarding Affiliated Companies sign now download form Word Document
Affidavit of Domestic Partnership sign now download form

 

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    
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 a change to an existing BCBSIL policy N/A download form
Group Enrollment Application/Change Form – Spanish N/A download form

 

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 a change to an existing BCBSIL policy N/A download form
Group Enrollment Application/Change Form – Spanish 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 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
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) – 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
Prescription Drug Mail-Order Form (AllianceRx Walgreens Pharmacy) – Members with BCBSIL HMO prescription drug coverage can use AllianceRx Walgreens Pharmacy to order new or refill maintenance prescription drugs for home delivery. Mail the completed form to the address provided on the form, and include the original prescription signed by your doctor. N/A download form
Prescription Drug Mail-Order Form (AllianceRx Walgreens Pharmacy) – Spanish N/A download form
Prescription Drug Mail-Order Form (Express Scripts) – Members with BCBSIL PPO or HMO prescription drug coverage can use Express Scripts Pharmacy to order new or refill prescription drugs for home delivery. They need to mail the completed form to the address provided on the form, and include the original prescription signed by their doctor. N/A download form
Prescription Drug Mail-Order Form (Express Scripts) – Spanish N/A download form

 

Miscellaneous

Form Name Digital Form Download
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
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
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