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
Full-Time Status Certification for Owners, Partners, Proprietors sign now 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

 

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 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) 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 N/A download form
Information Regarding MSP Statute N/A download flier
MSP Fact Sheet N/A download flier

 

Prescription Drug Forms

Form Name Digital Form Download
Prescription Drug Claim Form (Prime Therapeutics) – Members with pharmacy benefits through BCBSIL can use this Prime Therapeutics claim form to request reimbursement for a prescription drug purchase. They must submit the original pharmacy receipt with the completed form. N/A download form
Prescription Drug Claim Form (Prime Therapeutics) – Spanish N/A download form
Prescription Drug Mail-Order Form (AllianceRx Walgreens Prime) – Members with BCBSIL HMO prescription drug coverage can use AllianceRx Walgreens Prime 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 Prime) – 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

 

Legal / HIPAA Forms

Form Name Digital Form Download
Standard Authorization Form and other HIPAA Privacy Forms N/A N/A