Blue Access for Producers
 

Downloadable Forms for Individual Products

Here are some commonly used forms for conducting business with Blue Cross and Blue Shield of Oklahoma (BCBSOK). To access more downloadable forms, please log in to Blue Access for Producers.

The forms below are in portable document format (PDF). To view these files, you may need to install a PDF reader program. Most PDF readers are a free download. One option is Adobe® Reader®.

Current Individual Forms
Stock # / Date Enrollment Forms and Change Forms Oklahoma Form #
73447.1115 Health Application/Change in Coverage Use this application for the 2016 plans only, which are effective January 1, 2016. DO NOT use the 2016 application for the 2015 plans.  Also DO NOT use the 2015 application for the 2016 plans. N/A
73447.0714 Health Application/Change in Coverage  Use this application for the 2015 plans only.  DO NOT use the 2015 application for the 2016 plans. N/A
60001.1115 Dental Application/Change in Coverage Use this application for the 2016 plans only, which are effective January 1, 2016. DO NOT use the 2016 application for the 2015 plans.  Also DO NOT use the 2015 application for the 2016 plans. N/A
60001.1014 Dental Application/Change in Coverage  Use this application for the 2015 plans only.  DO NOT use the 2015 application for the 2016 plans. N/A
Stock # / Date Account Maintenance Forms Oklahoma Form #
72008.0713 Automated Premium Payment Authorization Agreement  N/A
Stock # / Date Legal / HIPAA Forms Oklahoma Form #
10.30.13 Standard Authorization Form and other HIPAA Privacy Forms N/A


Pre-ACA Individual Forms
Stock # / Date Enrollment Forms and Change Forms Oklahoma Form #
72120.1113 Health Check and Simply Blue Individual Application and Change in Membership  N/A
71269.1210 BlueSelect Dental Application  N/A
70304.0811 Application for Individual Temporary Insurance Coverage  N/A
Stock # / Date Account Maintenance Forms Oklahoma Form #
72008.0713 Automated Premium Payment Authorization Agreement  N/A
Stock # / Date Legal / HIPAA Forms Oklahoma Form #
10.30.13 Standard Authorization Form and other HIPAA Privacy Forms N/A