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Downloadable Forms

Get the most from your health insurance coverage by using these helpful forms and documents to make plan changes, add features, file claims and much more.

Note: Forms on this page are available as PDF files. Just click on the appropriate form to view, download and print. You will need the Adobe® Reader® to access these files, which you can download for free at Adobe's site . If these downloadable PDF forms are altered in any way they will not be processed by Blue Cross and Blue Shield of Oklahoma.

Customer Service


Form Name and Description Revision Date
2014 Oklahoma Individual Product Under 65 Off Exchange Medical Application or Change in Coverage

English 

Spanish 
Updated 01/2014
Certificate of Creditable Coverage Submission Form  (55kB)
This form is used to submit a certificate of creditable coverage (COCC) or CDIB Card.
Updated 12/2009
BCBSOK Medical Claim Form (member-submitted)  (90kB) Updated 03/2012
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.
Updated 03/2012
Dependent Student Medical Leave Form  (33kB) Added on 01/2011
COB Questionnaire - Blue Cross and Blue Shield of Oklahoma  (34kB) Updated 03/2008
COB Questionnaire - BlueLincs (39kB)
BlueLincs Coordination of Benefits Questionnaire
Updated 09/2005

Dental Forms


Form Name and Description Revision Date
Dental Claim Form  (145kB) Updated 01/2012
Dental Provider Nomination Form  (54kB)
Use this form to nominate a dental provider (dentist) to be in the network.
 

Individual/Family Coverage


Form Name and Description Revision Date
Product Guides
Product Guide Brochure  (1329kB)
Or call toll-free 1-866-793-8111 for more information
Updated 08/2012
Plan Comparison Chart  (359kB) Updated 06/2011
Health Check and Simply Blue
Health Check and Simply Blue Individual Application and Change in Membership  (178kB) Updated 06/2011
Health Check and Simply Blue Change Form  (82kB) Updated 08/2011
Simply Blue Outline of Coverage  (194kB) Updated 06/2012
Simply Blue Producer Acknowledgement  (66kB) Updated 06/2011
List Bill Materials (3 forms)  (273kB) Updated 06/2011
Blue Transitions
Blue Transitions Application  (725kB) Updated 08/2011
Blue Transitions Debit Authorization Form  (50kB) Updated 02/2009
Dental (BlueSelect)
BlueSelect Dental application  (60kB) Updated 12/2010
Request For Underwriting Opinion
Request For Underwriting Opinion Form  (37kB)  

Medicare Supplement


Form Name and Description Revision Date
Product Guide
Plan65 and Blue Plan65 Select Brochure  (990kB) Updated 03/2011
Application Forms

Plan65 and Blue Plan65 Select Application  (223kB)

Updated 03/2010

Information Regarding The Medicare as Secondary Payer Statute  (64kB)

Updated 02/2007

Medicare Secondary Payer Employer Acknowledgment  (47kB)

Updated 02/2007

Outline of Coverage
Plan65 and Blue Plan65 Select Outline of Coverage  (649kB) Updated 01/2011
Sales Materials
Plan65 and Blue Plan65 Select Benefit Chart and Rates  (90kB) Updated 01/2011

Prescription Drug Forms


Form Name and Description Revision Date
PrimeMail New Prescription Order Form  (236kB)
Members with BCBSOK prescription drug coverage can use this form to mail order new prescription maintenance medication. Mail the completed form to PrimeMail, and include the original prescription signed by your doctor.
Updated 12/2010
PrimeMail Refill Prescription Order Form  (362kB)
Members with BCBSOK prescription drug coverage can use this form to mail order refills for prescribed maintenance medication.
Updated 12/2010
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. You must submit the original pharmacy receipt with the completed form to Prime Therapeutics, the BCBSOK pharmacy benefits manager.
Updated 01/2012
Prescription Drug Claim Form (for Individual Plan members)  (216kB)
BCBSOK members with pharmacy benefits through an individual insurance plan can use this form to request reimbursement for a prescription drug purchase. You must submit the original pharmacy receipt with the completed form to Prime Therapeutics, the BCBSOK pharmacy benefits manager.
Updated 01/2013

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