Downloadable Forms for 2-50 Employees
|
BlueCare Dental - PPO
|
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|---|---|---|---|
|
Form Name |
Form Number |
Date |
|
| For Dental Only | |||
Dental Claim Form  |
#20350 |
01/12 |
|
| For BAE/Dental | |||
2017 Benefit Program Application (BPA)  |
#IL-SG-HP-BPA |
05/16 |
|
| Employer Group Information Form (new group) |
#IL Small Group EGI |
01/16 |
|
| Enrollment Change Request Form |
#22735 |
06/10 |
|
| Submission Guidelines for Small Group Health Coverage |
#23162 |
02/11 |
|
| Small Group Standard Health Application |
#22997, #23071 |
12/11, 01/11 |
|
| HMO/CPO Provider Selection Enrollment and Change Form |
#22840 |
01/11 |
|
| Small Group Benefit Plan Selection Form for accounts effective 1/1/17 and after |
#GA-RSG 2017-BPS |
09/16 |
|
| Small Group Benefit Plan Selection Form for accounts effective 1/1/17 and after |
#GA-RSG 2017-BPS |
09/16 |
|
| Small Group Benefit Plan Selection Form for accounts effective 1/1/16 and after |
#GA-RSG 2016-BPS |
11/15 |
|
| Small Group Benefit Plan Selection Form for accounts effective 1/1/16 and after |
#GA-RSG 2016-BPS |
11/15 |
|
| Small Group Benefit Plan Selection Form for accounts effective 1/1/15 and after |
#GA-RSG 2015-BPS |
11/14 |
|
| Small Group Benefit Plan Selection Form for accounts effective 1/1/15 and after |
#GA-RSG 2015-BPS |
11/14 |
|
| Small Group Benefit Plan Selection Form for accounts effective 1/1/13 and after |
#GA-10-9-SMGRP BPSF |
01/13 |
|
| Small Group Benefit Plan Selection Form for accounts effective 7/1/12 and after |
#GA-10-9-SMGRP BPSF |
07/12 |
|
|
#IL-SG-HP-BPA |
05/15 |
||
| General Notice of Special Enrollment Rights |
#22963 |
04/15 |
|
| Notice of Information Practices |
#EB4644 |
03/04 |
|
| HIPAA Notice of Privacy Practices | |||
| Standard Authorization Form and other HIPAA Privacy Forms | |||
| Affidavit of Domestic Partnership |
#20551 |
01/05 |
|
| Statement of Termination of Domestic Partnership |
#20560 |
02/07 |
|
| Tax Information on Health Benefits for Domestic Partnership |
#20559 |
02/07 |
|
| New Business Checklist for SG Regulated |
#227019 |
09/14 |
|
| Dental Claim Form |
#20350 |
01/12 |
|
| 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). |
#238412.0819 |
08/19 |
|
| AD Change Form |
|
11/14 |
|
