Blue Access for Employers
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Employer Forms

Form Name and DescriptionRevision Date

Enrollment Application/Change Form — English  (222kB) Spanish  (248kB)

Updated 09/2011

Small Business Enrollment Application/Change Form

  — English  Spanish  (143kB)
Updated 10/2011
Standard Authorization Form and other HIPAA Privacy Forms
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  (58kB)  
BlueSelect Dental Application  (140kB)  
BCBSOK Medical Claim Form (member-submitted)  (90kB)
Updated 03/2012
Certificate of Coverage  (80kB)
 
Common Law Marriage Affidavit  (31kB)
 
Dental Claim Form  (145kB)
Updated 01/2012
Medicare Secondary Payer (MSP) Employer Acknowledgement Form with Instructions  (155kB)
Updated 01/2011
Information Regarding Medicare Secondary Payer (MSP) Statute   (301kB)
Updated 01/2011
MSP Fact Sheet  (388kB)
Updated 06/2012
Plan65 Blue Plan65 Select Application  (223kB)
 
Dependent Student Medical Leave Form  (33kB)
Added 01/2011
Comprehensive Prescription Drug Claim Form  (37kB)
Updated 02/2009
Prescription Drug Claim Form (for Group Plan members)  (264kB)
BCBSOK members with pharmacy benefits through an employer group insurance plan can use this form to request reimbursement for a prescription drug purchase. Members must submit the original pharmacy receipt with the completed form to Prime Therapeutics, the BCBSOK pharmacy benefits manager.
Updated 01/2012

 

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