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
Certificate of Creditable Coverage Submission Form  This form is used to submit a certificate of creditable coverage (COCC) or CDIB Card.	Updated 12/31/09
BCBSOK Health Benefits Claim Form  (63.5 KB)
BCBSOK Authorization to Disclose Protected Health Information (Instructions) This form provides a sample for the standard authorization form below. (52 KB)
BCBSOK Authorization to Disclose Protected Health Information  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. (73 KB)	Updated 2/04/08
BlueLincs Authorization to Disclose Protected Health Information 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. (61 KB)	Updated 9/20/05
Student Certification Form 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. (51 KB)	Updated 02/08/10
Dependent Student Medical Leave Form  (38 KB)	Added on 9/23/09
COB Questionnaire - Blue Cross and Blue Shield of Oklahoma  (34.4 KB)	Updated 03/08
COB Questionnaire - BlueLincs BlueLincs Coordination of Benefits Questionnaire (39 KB)	Updated 9/20/05
BCBSOK Request to Access Protected Health Information This form allows an individual to request his or her own PHI. (24 KB)	Updated 10/06/08
BCBSOK Request to Amend Protected Health Information This form allows an individual to request amendments to his or her own PHI. (24 KB)	Updated 10/06/08
BCBSOK Confidential Communication Request Form 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. (32 KB)	Updated 10/06/08
BCBSOK Request for Accounting of Protected Health Information Disclosures 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. (22 KB)	Updated 10/06/08
Response to Denied Amendment 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. (22 KB)	Updated 10/06/08
Restriction Request Form 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. (30 KB)	Updated 10/06/08
HIPAA Complaint Form Use this form to file a HIPAA complaint (including privacy and security) with Blue Cross and Blue Shield of Oklahoma. (22 KB)	Updated 10/06/08

Dental Claim Form

Form Name and Description	Revision Date
Dental Claim Form	Updated 08/14/09

Vision Claim Form

Form Name and Description	Revision Date
Vision Claim Forms	Updated 3/1/2006

Individual/Family Coverage

Form Name and Description	Revision Date
Health Check
Brochure about Health Check  (2.04 MB) Or call toll-free 1-866-303-BLUE (2583) for more information	Updated 12/08/09
Health Check application  for Health Check Basic, Select (1.9 MB)	Updated 12/08/09
Health Check change in membership form with no health statement  (113 KB)	Updated 12/08/09
Dental (BlueSelect)
BlueSelect Dental application  (118 KB)	Updated 3/30/05
Request For Underwriting Opinion
Request For Underwriting Opinion Form  (37 KB)

Prescription Drug Information

Form Name and Description	Revision Date
Comprehensive Prescription Drug Claim Form  (37 KB)	Updated 02/2009
Drug Card Prescription Claim Form  (464 KB)	Updated 12/2007