Employer Forms
| Forms | Description |
|---|---|
|
Enrollment Application/Change Form — English |
Enrollment Application/Change Form, Enrollment Application/Change Form — Spanish |
|
Small Business Enrollment Application/Change Form — English Spanish [file: 143KB] (Updated 10/2011) |
Small Business Enrollment Application/Change Form |
| BCBSOK Authorization to Disclose Protected Health Information (Instructions) [file: 52 KB] |
Sample of the standard authorization form below. |
| BCBSOK Authorization to Disclose Protected Health Information [file: 73 KB] |
Authorizes Blue Cross and Blue Shield of Oklahoma to disclose protected health information only to those individuals specified by the member. Protected health information is defined by privacy rules enacted under the Health Insurance Portability and Accountability Act (HIPAA) of 1996. |
| BCBSOK COBRA Continuation Coverage [file:58.1 KB] |
BCBSOK COBRA |
| BlueLincs Health Claim Form [file: 87.9KB] |
BlueLincs Health Claim Form |
| BlueLincs Authorization to Disclose Protected Health Information [file: 61 KB] (Updated 09/20/05) |
Authorizes BlueLincs HMO to disclose protected health information only to those individuals specified by the member. Protected health information is defined by privacy rules enacted under the Health Insurance Portability and Accountability Act (HIPAA) of 1996. |
| BlueSelect Dental Application [file: 140 KB] |
BlueSelect Dental Application |
| BCBSOK Health Claim Form [file: 63.5 KB] |
BCBSOK Health Claim Form |
| Certificate of Coverage [file: 79.7 KB] |
Certificate of Coverage |
| Common Law Marriage Affidavit [file: 31 KB] |
Common Law Marriage Affidavit |
| Dental Claim Form [file: 6.3 MB] (Updated 08/14/09) |
Dental Claim Form |
| How to file BlueLincs HMO Claims [file: 72.2 KB] |
How to File BlueLincs HMO Claims |
| Medicare Secondary Payer Employer Acknowledgement [file 110 KB] (Updated 01/2011) |
Medicare Secondary Payer Employer Acknowledgement |
| Medicare as Secondary Payer Information [file 64 KB] |
Information regarding The Medicare Secondary Payer Statue |
| Plan65 Blue Plan65 Select Application [file: 223 KB] |
Plan65 Blue Plan65 Select Application |
| Student Certification Form [file: 41 KB] (Updated 02/08/10) |
This form is required for members to continue health and/or dental coverage for their dependent child age 19 or older, as long as he or she is an unmarried, full-time student. |
| Dependent Student Medical Leave Form [file: 38 KB](Added on 09/23/09) |
Dependent Student Medical Leave Form |
| Vision Claim Form [file: 45 KB] (Updated 03/01/06) |
Vision Claim Form |
| Comprehensive Prescription Drug Claim Form [file: 7 KB] (Updated 02/2009) |
Comprehensive Prescription Drug Claim Form |
| Drug Card Prescription Claim Form [file: 465 KB] (Updated 12/2007) |
Drug Card Prescription Claim Form |
