Download PDF forms related to:  

• Caring Foundation 
• Company Information
• Customer Service Forms
• Dental Claim Forms
• Health Care Provider Forms
• Individual Forms
• Group Forms
• Prescription Drug Information
• Vision Claim Form

Caring Foundation  

• Tribute Gift Brochure [printable donation form: 268 KB] (Updated 10/20/2008)
• Oklahoma Caring Foundation brochure [File: 3,370 KB] [Updated: 11/6/09]
• The Oklahoma Caring Foundation 2008 Annual Report [File: 2,047 KB] [Updated 6/23/2009]

Company Information

• View the Code of Business Conduct Policy for the Blue Cross and Blue Shield of Oklahoma Family of Companies. [File: 82 KB] (Updated 7/25/05)

Customer Service

• BCBSOK Health Benefits Claim Form [63.5KB]
• BCBSOK Authorization to Disclose Protected Health Information (Instructions) [File: 52 KB] - This form provides a sample for the standard authorization form below.
• 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 7/13/09)
• Dependent Student Medical Leave Form [File: 38 KB] [Added on 9/23/09] 
• COB Questionnaire - Blue Cross and Blue Shield of Oklahoma  [File: 34.4 KB]  [Updated 03/08]
• 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: 24 KB] - This form allows an individual to request his or her own PHI. (Updated 10/06/08)
• BCBSOK Request to Amend Protected Health Information [File: 24 KB] - This form allows an individual to request amendments to his or her own PHI. (Updated 10/06/08)
• 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 10/06/08)
• BCBSOK Request for Accounting of Protected Health Information Disclosures [File: 22 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 10/06/08)
• Response to Denied Amendment [File: 22 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 10/06/08)
• 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 10/06/08)
• HIPAA Complaint Form [File: 22 KB] - Use this form to file a HIPAA complaint (including privacy and security) with Blue Cross and Blue Shield of Oklahoma. (Updated 10/06/08) 

Dental Claim Forms

• Dental Claim Form (Updated 08/14/09)

Health Care Provider - Forms

• Accidental Injury Questionaire [File: 24 KB]
• BlueLincs HMO Allergy Authorization Request [File: 78 KB] [Added 04/27/09]
• Predetermination Request Form [File: 69 KB] [Added 04/27/09]
• Triessent Fax Form [File: 168 KB]
• Wheelchair Medical Necessity and Home Evaluation Verification [File: 26 KB]
• Provider Practice Change Form  [File: 48.8 KB]  
• Claim Appeal/Reconsideration Review Request  [File: 60 KB]  [Updated 02/02/09]
• Immunoglobulin Therapy Request Form  [File: 27.5 KB] - [Updated 06/30/08]
• COB Questionnaire Form [File: 34.4 KB] - [Updated 03/08]
• Synagis Statement of Medical Necessity [File: 195 KB] - [Updated 09/18/09] – This form is for the predetermination/authorization of the medication Synagis used in the prevention of repiratory syncytial virus (RSV).
• UB-04 User Guide [File: 223 KB] - Updated 9/11/08] - This guide will help providers complete the UB-04 form for patients with Blue Cross (facility) coverage.
• CMS-1500 User Guide  [File: 98 KB] - [Updated May 2008] This guide will help providers complete the CMS-1500 (08/05) form for patients with Blue Cross and Shield of Oklahoma insurance. 
• BCBSOK Significant Edits as of Jan. 9, 2009  [File: 39 KB] - [Updated 01/09/09]
• BCBSOK Significant Edits as of Nov. 3, 2009 [File: 128 KB] - [Updated 11/03/09] New!     
• CPT-4 Modifier Use in Claims Processing [File: 81 KB] - Information about using modifiers when submitting claims to Blue Cross and Blue Shield of Oklahoma.(Updated 9/20/05)
• BCBSOK Authorization to Disclose Protected Health Information (Instructions) [File: 52 KB] - This form provides a sample for the standard authorization form below.
• BCBSOK Authorization to Disclose Protected Health Information [File: 33 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 10/01/07)   
• 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)
• BlueLincs HMO Referral / Authorization Request [File: 105 KB] - Information that BlueLincs needs for referrals and authorizations. (Updated 9/26/08)
• PAVET^TM Evaluation for Microprocessor Knee [File: 104 KB] (Updated 12/28/07)

Dental

• Attending dentist's statement [File: 80 KB] - Complete and mail to assure timely payment of submitted claims. (Updated 3/30/06)

Individual/Family coverage

Health Check

• Brochure about Health Check  [File: 2.04 MB], or call toll-free 1-866-303-BLUE (2583) for more information (Updated 07/18/08)
• Health Check application   [File: 1.9 MB] for Health Check Basic, Select (Updated 07/18/08)
• Health Check change in membership form with no health statement  [File: 113 KB] (Updated 07/18/08)

Dental (BlueSelect)

• BlueSelect Dental application [118 KB] (Updated 3/30/05)

Request For Underwriting Opinion    

• Request For Underwriting Opinion Form  [File: 37 KB] 

Group (employer) coverage

NEW: Benefit Program Application (for groups with effective dates of Jan. 1, 2010 and after)

HSA Blue

• Learn more about HSA Blue [File: 117 KB] (Updated 7/25/05)
• Frequently Asked Questions (FAQs) about HSA Blue [File: 71 KB] (Updated 4/09/08)

Oklahoma Manufacturer’s Health Plan 

• Learn more about Oklahoma Manufacturer’s Health Plan  [File: 88 KB] (Updated 7/24/09) New!

BlueOptions®

• Questions about BlueOptions PPO? Here are the answers. [File: 58 KB] (Updated 7/24/09) New! 
• Download the new BlueOptions PPO brochure. [File: 1,397 KB] (Updated 7/24/09) New!

Dental:

• Group Dental Application\Request for Change in Dental Membership Form [File: 112 KB] (Updated 9/2/08)

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

Groups 2-4

• Small Business Application\Request for Change in Membership\Decline Form [File: 143KB] (Updated 9/17/08)
  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

• Rate Quotation Form [File: 33KB] (Updated 7/25/05)

Groups 2-4, 5-9, 10+

• Census Form [File: 71KB] (Updated 7/25/05)
• Small Business Fax Cover Page [File: 54KB] (Updated 7/25/05)

Groups 5-9, 10+

• Group Employer Medical Questionnaire (formally known as the Group Appraisal Form)   [File: 1.66 MB] (Updated 09/29/08)

Groups 10+

• Group Enrollment Application\Request for Change in Membership\Decline Form [File: 128KB] (Updated 08/29/08)
• 10-99 Rate Quotation Checklist [File: 39KB] or
  100+ Rate Quotation Checklist [File: 39KB] (Both updated 7/25/05)
• Request for Proposal [File: 930KB] (Updated 7/25/05)

Prescription Drug Information

• Prescription Drug Formulary (alphabetical) [File: 357 KB]  (Updated 04/07/09)   
• Prescription Drug Formulary (therapeutic) [File: 242 KB [Updated 01/20/09]
• Commonly prescribed drugs requiring preauthorization [File: 39 KB]  (Updated 7/01/07)    
• Maintenance Drug Listing [File: 46 KB] (Updated 02/09)   
• Prescription Drugs with Quantity Limits [File: 38 KB] (Updated 07/01/08)
• Generic v. brand name price comparison chart  [File: 48 KB] (Updated 07/01/08)
• Comprehensive Prescription Drug Claim Form [File: 37 KB] (Updated: 02/09)

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

• Top 10 facts on generic drugs [File: 114 KB]  
• FDA ensures equivalence of generic drugs [File: 305 KB]  
• The story behind the rising cost of prescription drugs [File: 79 KB]  

U.S. Food and Drug Administration posters

• No. 1: Think it's easy becoming a generic drug in America? Think again. [File: 712 KB]  
• No. 2: You know that question that goes through your mind when you take your generic drug? Here's your answer [File: 412 KB]  
• No. 3: If you're experiencing anxiety about taking your generic drug, read this ad and repeat as needed. [File: 163 KB]