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Forms

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Caring Foundation

Company Information

Customer Service

  • BCBSOK Authorization to Disclose Protected Health Information  [File: 73 KB] - This form 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. (Updated 2/04/08)
  • BlueLincs Authorization to Disclose Protected Health Information [File: 61 KB] - This form 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. (Updated 9/20/05)
  • Student Verification Form [File: 55 KB] - This form is required for you to continue health and/or dental coverage for your dependent child age 19 or older, as long as he or she is an unmarried, full-time student. (Updated 9/20/05)
  • COB Questionnaire - BlueLincs [File: 39 KB] - BlueLincs Coordination of Benefits Questionnaire (Updated 9/20/05)
  • BlueLincs Service Area [File: 159 KB] (Updated 9/20/05)
  • BCBSOK Request to Access Protected Health Information [File: 29 KB] - This form allows an individual to request his or her own PHI. (Updated 11/21/07)
  • BCBSOK Request to Amend Protected Health Information [File: 29 KB] - This form allows an individual to request amendments to his or her own PHI. (Updated 11/21/07)
  • BCBSOK Confidential Communication Request Form [File: 32 KB] - Use this form to request that Blue Cross and Blue Shield of Oklahoma use an alternative location when communicating with you about your Protected Health Information. (Updated 11/21/07)
  • BCBSOK Request for Accounting of Protected Health Information Disclosures [File: 20 KB] - Use this form to request an accounting of how your Protected Health Information was disclosed by Blue Cross and Blue Shield of Oklahoma or its Business Associates. (Updated 11/21/07)
  • Response to Denied Amendment [File: 28 KB] - Use this form to file a Statement of Disagreement regarding a denied Request for Amendment or to request that your original amendment request and subsequent denial be attached to future disclosures of the Protected Health Information that you had requested to be amended. (Updated 11/21/07)
  • Restriction Request Form [File: 30 KB] - Use this form to request the restrictions on Blue Cross and Blue Shield of Oklahoma's use or disclosure of your Protected Health Information for payment or health care operations purposes.  You may also use this form to terminate a previously granted request for restriction. (Updated 11/21/07)
  • HIPAA Complaint Form [File: 20 KB] - Use this form to file a HIPAA complaint (including privacy and security) with Blue Cross and Blue Shield of Oklahoma. (Updated 11/21/07)

Dental Claim Forms

Health Care Provider - Forms

Dental

Individual/Family coverage

Health Check

Health Check HSA

Dental (BlueSelect)

Plan 65 - free informational seminars for seniors

Group (employer) coverage

Health Reimbursement Accounts

HSA Blue

Oklahoma Manufacturer’s Health Plan 

BlueOptions®

Group rate quotes:
Please fill out all forms which apply to your group size

Groups 2-4

  • Small Business Application [File: 107KB] (Updated 7/25/05)
    Have each employee who plans to enroll in your health plan complete this form (including the health statement portion of the application).
    Please be sure to answer all questions.

Groups 2-4, 5-9

Groups 2-4, 5-9, 10+

Groups 5-9, 10+

Groups 10+

Prescription Drug Information

1 Note: Blue Cross and Blue Shield health plans offered by self-insured employer groups may have different coverage options, plans or benefits. Please refer to your health plan contract, which governs eligibility, coverage exclusions and available benefits.

Generic Drugs

U.S. Food and Drug Administration posters

Rising Cost of Insurance - Resources (All updated 7/25/05)

Brochures

The uninsured in America