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 1/1/24 and after | sign now | N/A | |
| 2024 Benefit Program Application (BPA) – For new accounts effective 1/1/24 and after | sign now | download form  download form |
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| 2024 Benefit Plan Selection (BPS) Form – For new accounts effective 1/1/24 and after | sign now | download form download form |
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| 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 | |
| Affordable Care Act (ACA) Small Group New Business Checklist | N/A | download form | |
| Full-Time Status Certification for Owners, Partners, Proprietors | sign now | download form download form |
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| General Notice of Special Enrollment Rights | N/A | download notice | |
| Underwriting Reference Guide for Brokers | N/A | download guide |
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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 |
| 2024 Benefit Plan Selection (BPS) Form – For new accounts effective 1/1/24 and after | sign now | download form download form |
| Small Group Billing Preferences Guide – For accounts effective 1/1/19 and after | N/A | download guide |
| Addendum to the Insured BPA Regarding Affiliated Companies | sign now | download form |
| 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 flier | |
| 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 |
| IL Employee Continuation Privilege Election Form | N/A | download form |
| 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 |
| 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 |