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 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 8/04/2011 |
| 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 7/05/2011 |
| 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 7/05/2011 |
| 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 |
| Dental Provider Nomination Form Use this form to nominate a dental provider (dentist) to be in the network. |
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 |
|---|---|
| Product Guides | |
| Product Guide Brochure (916 KB) Or cal toll-free 1-866-303-BLUE (2583) for more information |
Updated 06/2011 |
| Plan Comparison Chart (359 KB) |
Updated 06/2011 |
| Health Check | |
| Health Check Individual Application (736 KB) |
Updated 12/2010 |
| Health Check change in membership form with no health statement (113 KB) |
Updated 12/08/09 |
| Simply Blue | |
| Simply Blue Application (150 KB) |
Updated 04/2011 |
| Simply Blue Outline of Coverage (102 KB) |
Updated 03/2010 |
| Simply Blue Producer Acknowledgement (66 KB) |
Updated 06/2011 |
| Simply Blue Change Application (90 KB) |
Updated 06/2011 |
| List Bill Materials (3 forms) (273 KB) |
Updated 06/2011 |
| Blue Transitions | |
| Blue Transitions Application (725 KB) |
Updated 08/2011 |
| Blue Transitions Debit Authorization Form (50 KB) |
Updated 02/2009 |
| Dental (BlueSelect) | |
| BlueSelect Dental application (60 KB) |
Updated 12/2010 |
| Request For Underwriting Opinion | |
| Request For Underwriting Opinion Form (37 KB) |
|
Medicare Supplement
| Form Name and Description | Revision Date |
|---|---|
| Product Guide | |
| Plan65 and Blue Plan65 Select Brochure (990k) |
Updated 03/2011 |
| Application Forms | |
| Updated 03/2010 | |
|
Information Regarding The Medicare as Secondary Payer Statute (64k) |
Updated 02/2007 |
|
Updated 02/2007 |
|
| Outline of Coverage | |
| Plan65 and Blue Plan65 Select Outline of Coverage (649k) |
Updated 01/2011 |
| Sales Materials | |
| Plan65 and Blue Plan65 Select Benefit Chart and Rates (90k) |
Updated 01/2011 |
Prescription Drug Information
| Form Name and Description | Revision Date |
|---|---|
| PrimeMail New Prescription Order Form - English (172 KB) (37 KB) |
Updated 05/2010 |
| PrimeMail New Prescription Order Form - Spanish (167 KB) (37 KB) |
Updated 05/2010 |
| Comprehensive Prescription Drug Claim Form (37 KB) |
Updated 02/2009 |
| Drug Card Prescription Claim Form (464 KB) |
Updated 12/2007 |
