Downloadable Forms for Small Group Products (Groups of 2-50)

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.

New Business/Enrollment Forms

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
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 Word Document
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 Word Document
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.

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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.

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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.

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

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

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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.

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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.

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Underwriting Reference Guide for Brokers N/A download guide

 

Renewal Forms and Information

Form Name Digital Form Download
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 Word Document
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 Word Document
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

 

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 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

 

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 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

 

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
Individual MSP Form N/A download form
Information Regarding MSP Statute N/A download info
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) – 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

 

Miscellaneous

Form Name Digital Form Download
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

 

Legal / HIPAA Forms

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