Downloadable Forms for 151+ Employees
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BlueCare Dental — PPO
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|---|---|---|---|
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Form Name
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Form Number
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Date
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Employer Enrollment |
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General Notice of Special Enrollment Rights  |
#22963 |
04/15 |
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| HIPAA Notice of Privacy Practices |
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| Standard Authorization Form and other HIPAA Privacy Forms |
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| Affidavit of Domestic Partnership |
#20551 |
01/05 |
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| Statement of Termination of Domestic Partnership |
#20560 |
02/07 |
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| Tax Information on Health Benefits for Domestic Partnership |
#20559 |
02/07 |
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| Employer New Business Checklist |
#20910
|
03/07 |
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| BluePrint Benefit Program Application Form (BPA) |
#GA-10-9-BPR-AF-HCSC
|
09/12 |
|
Addendum to the Insured BPA Regarding Affiliated Companies (Word Doc)  |
#MGA-10-1-ADD
|
2007 |
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| ASO Benefit Program Application (BPA) Form |
#GA-10-4-HCSC
|
02/04 |
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| 100 Plus Insured Accounts Benefit Program Application (BPA) Form |
#MGA-10-1 UNI HCSC
|
10/10 |
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| Enrollment Change Request Form |
#22735
|
06/10 |
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Account Maintenance Forms |
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#20350
|
01/12 |
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| Disabled Dependent Authorization Form (for Group Plans) |
#238412.0819 |
08/19 |
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