Blue Access for Producers
 

Downloadable Forms for Mid-Market Group 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®. Other Adobe accessibility tools and information can be downloaded at access.adobe.com .

MID-MARKET GROUP FORMS (Groups of 51-150)
Stock # / Date Mid-Market Group - Enrollment Forms and Change Forms Oklahoma Form #
-- New Group Benefit Program Application 51-150  OKBPA51
-- 2015 Benefit Program Application Amendment (Existing Groups) 51-150  OKBPA51C
71855.0211 Checklist for Obtaining a Quote for New Groups 51-150  N/A
72234.0811 Checklist for Submitting Sold Non-Regulated Groups 51-150  N/A
601863.0814 Enrollment Application/Change Form  N/A
602488.0115 Enrollment Application/Change Form - Spanish  N/A
-- Deductible Credit Form for Employees at Enrollment  N/A
70381.0708 Group Employer Medical Questionnaire  N/A
71268.1010 Request for Continuation Coverage  N/A
 
Stock # / Date Mid-Market Group - Miscellaneous Forms Oklahoma Form #
600844.0114 Affidavit of Domestic Partnership  N/A
10.290 (07/06) Common Law Marriage Affidavit  N/A
 
Stock # / Date Medicare Secondary Payer (MSP) Form and Information Oklahoma Form #
21126.0913 Annual MSP Employer Acknowledgement Form with Instructions on Completing the Form N/A
21094.0609 Information Regarding the Medicare as Secondary Payer Statute N/A
72875.0612 MSP Fact Sheet N/A
 
Stock # / Date Legal / HIPAA Forms Oklahoma Form #
09.01.13 Standard Authorization Form and other HIPAA Privacy Forms N/A