Here are some commonly used forms for conducting business with Blue Cross and Blue Shield of Illinois (BCBSIL). 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.
Form Name | Digital Form | Download |
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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 |
2023 Enrollment Package – Includes Benefit Program Application (BPA), Benefit Plan Selection (BPS) Form, EGI Form, and Artifacts Documentation for new accounts effective 1/1/23 and after | sign now | N/A |
2023 Benefit Program Application (BPA) – For new accounts effective 1/1/23 and after | sign now | download form ![]() download form |
Employer Group Information (EGI) Form – This form must be submitted with the BPA | sign now | download form |
2023 Benefit Plan Selection (BPS) Form – For new accounts effective 1/1/2023 and after | N/A | download form ![]() download form |
Affidavit of Domestic Partnership | sign now | download form |
Affordable Care Act (ACA) Small Group New Business Checklist | N/A | 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 integration with BenefitWallet. |
N/A | download form |
Consumer Directed Health Accounts Enrollment and Change Form – Use this form to collect employee FSA 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 integration with Flex. |
N/A | download form |
Full-Time Status Certification for Owners, Partners, Proprietors | sign now | download form ![]() download form |
General Notice of Special Enrollment Rights | N/A | download notice |
HMO/CPO Provider Selection Enrollment and Change Form | 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. |
N/A | 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/FSA Employer Setup Form – HealthEquity® – Submit an electronic copy of this form for each employer wishing to elect HSA and/or FSA 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 and/or FSA integration with HSA Bank. |
N/A | download form |
Underwriting Reference Guide for Brokers | N/A | download guide |
Form Name | Digital Form | Download |
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2024 Important Benefit Changes/Uniform Modification Notice –Identifies some of the most important benefit plan changes for the 2024 coverage year. | N/A | download notice |
2023 Important Benefit Changes/Uniform Modification Notice – identifies some of the most important benefit plan changes for the upcoming 2023 coverage year | N/A | download notice |
2023 Benefit Plan Selection (BPS) Form – For new accounts effective 1/1/2023 and after | N/A | download form ![]() download form |
Small Group Billing Method Form | N/A | download form |
Small Group Billing Preferences Guide | N/A | download guide |
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 |
Addendum to the Insured BPA Regarding Affiliated Companies | sign now | download form ![]() |
2019 Significant Benefit Changes to Select Small Group Plans – for accounts renewing 1/1/19 and after | N/A | download letter |
2019 Small Group Billing Method Form – for accounts effective 1/1/19 and after | N/A | download form |
2019 Small Group Billing Preferences Guide – for accounts effective 1/1/19 and after | N/A | download guide |
2019 Small Group Renewal Tips – for accounts effective 1/1/19 and after | N/A | download flier |
Form Name | Digital Form | Download |
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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 guidlines |
General Notice of Special Enrollment Rights | N/A | download notice |
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 guidelines |
General Notice of Special Enrollment Rights | N/A | download notice |
Form Name | Digital Form | Download |
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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 |
Form Name | Digital Form | Download |
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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 info |
MSP Fact Sheet | N/A | download fact sheet |
Form Name | Digital Form | Download |
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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) – For HMO Group Plans and Individual Plans; 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) – For PPO and HMO Group Plans and Individual Plans; Members with BCBSIL 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 |
Women's Contraceptive Coverage List | N/A | download list |
Form Name | Digital Form | Download |
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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 |
2019 Small Group Billing Method Form – for accounts effective 1/1/19 and after | N/A | download form |
2019 Small Group Billing Preferences Guide – for accounts effective 1/1/19 and after | N/A | download guide |
2019 Small Group Renewal Tips – for accounts effective 1/1/19 and after | N/A | download flier |
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 |
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 |
Form Name | Digital Form | Download |
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Standard Authorization Form and other HIPAA Privacy Forms | N/A | N/A |