Downloadable Forms for Mid-Market Group Products (Groups of 51-150)

Here are some commonly used forms and documents producers need for conducting business with Blue Cross and Blue Shield of Illinois. To access more downloadable forms, please log in your Blue Access for ProducersSM account.

Using PDFs
Most of the forms below are in portable document format (PDF). To view these files, you may need to install a PDF reader program. Most PDF readers are a free download. One option is Adobe® Reader®.

“Sign Now” Documents
Some documents have a “sign now” option. To review and sign a document now electronically, select the sign now version. If you need to sign a document later, select the download version. These are available in PDF format and some may also be available in Microsoft Word format.

Download forms from the listing below or via our FormFinder tool.

FormFinder

 

 

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
2024 Enrollment Package – Includes Benefit Program Application (BPA), Benefit Plan Selection (BPS) Form, EGI Form and Artifacts Documentation for new accounts effective 7/1/2024 sign now N/A
2024 Benefit Program Application (BPA) – For new accounts effective 1/1/2024 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
Affidavit of Domestic Partnership sign now download form
BlueTrack Process Flier N/A download flier

Consumer Directed Health Accounts Enrollment and Change Form – Use this form to collect employee FSA and/or HRA elections if sending enrollment through BCBSIL to 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 and/or HRA integration with Flex.

 N/A download form
Full-Time Status Certification for Owners, Partners, Proprietors sign now download form Word Document
download form
HMO/CPO Provider Selection Enrollment and Change Form 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, FSA and/or HRA 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, FSA and/or HRA integration with HSA Bank.

 N/A download form
Extension Form sign now download form
Mid-Market Initial Premium EFT Payment Form sign now download checklist
Mid-Market New Business Checklist – for State Area Brokers N/A download checklist
Mid-Market New Business Checklist – for Chicago Metro Brokers N/A download form
Smart Census Import Tool
(To obtain the latest version of the tool, please log into Blue Access for Producers.)		 N/A N/A

 

Renewal Forms and Information

Form Name Digital Form Download
2023–2024 Important Benefit Changes/Uniform Modification Notice - Identifies some of the most important benefit plan changes for the 2023–2024 coverage year. N/A download notice
2024 Benefit Plan Selection (BPS) Form – For new accounts effective 7/1/2024 and after sign now download form Word Document
download form
Addendum to the Insured BPA Regarding Affiliated Companies sign now download form Word Document
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

 

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 guidelines
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 flier
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 flier
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) – 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) – 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 Forms

Form Name Digital Form Download
Small Group HCSC/FDL Disclosure Form N/A download form
Membership Change Request Form N/A download form
Employee Continuation Privilege Election Form N/A download form
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
Dependent Student Medical Leave Certification Form 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

 

Last Updated: May 21, 2024