Downloadable Forms for Mid-Market Groups (51-150 Employees)
Here are some commonly used forms for conducting business with Blue Cross and Blue Shield of Illinois (BCBSIL). Non-regulated cases with 51 or more total employees on average over the prior calendar year including all eligible and ineligible employee types such as temporary, union, seasonal, and part-time employees. This includes employees of controlled/affiliated entities and domestic parent companies.
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
Form Name | Digital Form | Download |
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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 |
2022 Enrollment Package – Includes Benefit Program Application (BPA), Benefit Plan Selection (BPS) Form, EGI Form and Artifacts Documentation for new accounts effective 1/1/22 and after | sign now | N/A |
2022 Benefit Program Application (BPA) – For new accounts effective 1/1/2022 and after | sign now | N/A |
2021 Enrollment Package – Includes Benefit Program Application (BPA), Benefit Plan Selection (BPS) Form, EGI Form and Artifacts Documentation for new accounts effective 7/1/2021 and after | sign now | N/A |
2021 Benefit Program Application (BPA) – For new accounts effective 1/1/2021 and after | sign now | download form download form |
2021 Benefit Plan Selection (BPS) Form – For new accounts effective 7/1/2021 and after | sign now | download form download form |
Employer Group Information (EGI) Form – This form must be submitted with the BPA | sign now | download form |
Illinois Extension Form | sign now | download form |
HMO/CPO Provider Selection Enrollment and Change Form | N/A | download form |
Mid-Market New Business Checklist – for State Area Brokers | N/A | download form |
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 |
Full-Time Status Certification for Owners, Partners, Proprietors | sign now | download form |
Affidavit of Domestic Partnership | sign now | download form |
BlueTrack Process Flier | N/A | download flier |
Mid-Market Initial Premium EFT Payment Form | sign now | download form |
Renewal Forms and Information
Form Name | Digital Form | Download |
---|---|---|
Group Enrollment Application/Change Form – Use this form to make changes 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 |
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 |
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 |
HMO/CPO Provider Selection Enrollment and Change Form | N/A | download form |
Claim Forms
Form Name | Digital Form | Download |
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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) – Members with pharmacy benefits through BCBSIL can use this Prime Therapeutics claim form to request reimbursement for a prescription drug purchase. They must submit the original pharmacy receipt with the completed form. | 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 |
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Annual Medicare Secondary Payer (MSP) Employer Acknowledgement Form with Instructions | sign now | 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) – Members with pharmacy benefits through BCBSIL can use this Prime Therapeutics claim form to request reimbursement for a prescription drug purchase. They must submit the original pharmacy receipt with the completed form. | N/A | download form |
Prescription Drug Claim Form (Prime Therapeutics) – Spanish | 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 (AllianceRx Walgreens Prime) – Spanish | N/A | download form |
Prescription Drug Mail-Order Form (Express Scripts) – for PPO and HMO Group Plans and Individual Plans | N/A | download form |
Prescription Drug Mail-Order Form (Express Scripts) – Spanish | N/A | download form |
Women's Contraceptive Coverage List | N/A | download list |
Miscellaneous
Form Name | Digital Form | Download |
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Small Group HCSC/FDL Disclosure 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 |
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 |
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Standard Authorization Form and other HIPAA Privacy Forms | N/A | N/A |