Downloadable Forms for Large Groups (151+ Employees)

Here are some commonly used forms for conducting business with Blue Cross and Blue Shield of Illinois (BCBSIL). The forms provided in this section are applicable to groups with 151+ enrolled lives.

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 for PPO/Non-HMO

Form Name	Digital Form	Download
Group Enrollment Application/Change Form – use this form to apply for group coverage or to make a change to an existing BCBSIL policy	N/A	download form
Group Enrollment Application/Change Form – Spanish	N/A	download form
Addendum to the Insured BPA Regarding Affiliated Companies	sign now	download form
Affidavit of Domestic Partnership	sign now	download form
Full-Time Status Certification for Owners, Partners, Proprietors	sign now	download form

New Business/Enrollment Forms for HMO (BlueAdvantage HMO and HMO Illinois)

Form Name	Digital Form	Download
Group Enrollment Application/Change Form – use this form to apply for group coverage or to make a change to an existing BCBSIL policy	N/A	download form
Group Enrollment Application/Change Form – Spanish	N/A	download form
Addendum to the Insured BPA Regarding Affiliated Companies	sign now	download form
Affidavit of Domestic Partnership	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 a change to an existing BCBSIL policy	N/A	download form
Group Enrollment Application/Change Form – Spanish	N/A	download form

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 a change to an existing BCBSIL policy	N/A	download form
Group Enrollment Application/Change Form – Spanish	N/A	download form

Claim Forms

Form Name	Digital Form	Download
Dental Claim Form	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)	N/A	download form

Medicare Secondary Payer (MSP) Forms and Information

Form Name	Digital Form	Download
Annual Medicare Secondary Payer (MSP) Employer Acknowledgement Form with Instructions	N/A	download form
Information Regarding Medicare as Secondary Payer Statute	N/A	download flier
MSP Fact Sheet	N/A	download flier

Prescription Drug Forms

Form Name	Digital Form	Download
Prescription Drug Claim Form (Prime Therapeutics)	N/A	download form
Prescription Drug Mail-Order Form (AllianceRx Walgreens Prime) – for HMO Group Plans and Individual Plans	N/A	download form
Prescription Drug Mail-Order Form (Express Scripts) – for PPO and HMO Group Plans and Individual Plans	N/A	download form

Miscellaneous

Form Name	Digital Form	Download
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
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

Legal / HIPAA Forms

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