Employer Forms

Having the information you need at your fingertips is vital when making business decisions. At Blue Cross and Blue Shield of Oklahoma (BCBSOK), we are committed to providing the resources, tools and information you need to help you make the best choices for your employees and your business. And we're committed to helping you stay informed with new postings on legislative updates, new member services and programs, and more. 

Form Name and Description

Revision Date

Group Enrollment Application/Change Form 
Use this form to apply for group coverage or to make a change to an existing policy.

07/2018

Group Enrollment Application/Change Form – Spanish

07/2018

2022 Enrollment Package for Small Groups 2-50 
Includes Small Group Benefit Program Application (BPA), EGI Form, and Artifacts Documentation for new accounts effective 1/1/22 and after

10/2021
2023 Benefit Program Application (BPA) for Small Groups 2-50
2023 Benefit Program Application (BPA) for Small Groups 2-50 Word Document
For new Small Group accounts effective on or after 1/1/2023.
06/2022
2023 Benefit Program Application (BPA) Amendment for Small Groups 2-50
2023 Benefit Program Application (BPA) Amendment for Small Groups 2-50 Word Document
For renewing Small Group accounts with anniversary dates on or after 1/1/2023; use this form to amend the original BPA.
06/2022
Employer Group Information (EGI) Form for Small Groups
This form must be submitted with the BPA
11/2022
Employer Group Information (EGI) Form for Mid Market Groups
This form must be submitted with the BPA
11/2022

2022 Benefit Program Application (BPA) for Small Groups 2-50
2022 Benefit Program Application (BPA) for Small Groups 2-50 Word Document
For new Small Group accounts effective on or after 1/1/2022.

06/2021

2022 Benefit Program Application (BPA) Amendment for Small Groups 2-50
2022 Benefit Program Application (BPA) Amendment for Small Groups 2-50 Word Document
For renewing Small Group accounts with anniversary dates on or after 1/1/2022; use this form to amend the original BPA.

06/2021

2023 Benefit Program Application (BPA) for Mid-Market Groups 51-150
2023 Benefit Program Application (BPA) for Mid-Market Groups 51-150 Word Document
For new Mid-Market Group accounts effective on or after 1/1/2023.

10/2022

2023 Benefit Program Application (BPA) Amendment for Mid-Market Groups 51-150
2023 Benefit Program Application (BPA) Amendment for Mid-Market Groups 51-150 Word Document
For renewing Small Group accounts with anniversary dates on or after 1/1/2023; use this form to amend the original BPA.

10/2022

2022 Benefit Program Application (BPA) for Mid-Market Groups 51-150
2022 Benefit Program Application (BPA) for Mid-Market Groups 51-150 Word Document
For new Mid-Market Group accounts effective on or after 1/1/2022.

06/2021
2023-2024 Important Small Group Benefit Changes/Uniform Modification Notice
Identifies some of the most important benefit plan changes for the upcoming 2023-2024 coverage year.
03/2023
COBRA Request for Continuation of Coverage 
Application to request continued coverage due to employee's reduction in work hours, retirement, termination, etc.
10/2010 
Claim Form – Dental 
Use this form to file dental claims for reimbursement that are not filed by your dental provider.
05/2022
Claim Form – Dental – Spanish
05/2022
Claim Form – Medical (Domestic) 
Plan members can use this form to request reimbursement for health care services obtained within the U.S., a U.S. territory, when on a cruise ship, or on a U.S. military base.
10/2015
Claim Form – Medical (Domestic) – Spanish 
01/2016
Claim Form – Medical (International) 
Plan members can use this claim form to request reimbursement for health care services obtained when traveling internationally - when outside of the U.S. or a U.S. territory, but NOT for services obtained on a cruise ship or a U.S. military base.
01/2017
Claim Form – Medical (International) – Spanish 
01/2017
Claim Form – Prescription Drug (Prime Therapeutics) 
Members with pharmacy benefits through BCBSTX can use this Prime Therapeutics claim form to request reimbursement for purchasing a prescription drug or over-the-counter (OTC) COVID-19 diagnostic home test kit. For prescription drugs, you must submit the original pharmacy receipt with the completed form. For COVID-19 home test kits, you must submit the original cash register or online receipt with the completed form.
03/2022
Claim Form – Prescription Drug (Prime Therapeutics) – Spanish 03/2022
Claim Form – Prescription Drug (Comprehensive Benefit) 
Only BCBSOK members with the comprehensive prescription drug benefit should use this claim form to request reimbursement from a non-participating pharmacy.
02/2009
Affidavit of Domestic Partnership 01/2014
Common Law Marriage Affidavit 09/2019
Medicare Secondary Payer (MSP) Employer Acknowledgement Form (EAF) with Instructions 
In the absence of employer-provided employee counts, the Centers for Medicare and Medicaid Services (CMS) requires the employer group health insurance plan be considered primary to Medicare. PDF includes the Annual Medicare Secondary Payer Employer Acknowledgement Form and Instructions for completing the form.
04/2021
Information Regarding Medicare Secondary Payer (MSP) Statute  
06/2009 
MSP Fact Sheet 
06/2012
Disabled Dependent Authorization Form (for Individual Plans) 
Members with an Individual health plan should use this form to request continuation of coverage on their existing policy for a dependent who is incapable of self-support because of mental or physical impairment. 
07/2019
Disabled Dependent Authorization Form (for Group Plans) 
Members with an employer-sponsored health plan should use this form to request continuation of coverage on their existing policy for a dependent who is incapable of self-support because of mental or physical impairment. This form can also be used to add a disabled dependent to a new policy.
10/2022
Dependent Student Medical Leave Form 
Public law 110-381 is known as Michelle's Law. Use this form when a dependent college student insured under the parent's policy must take a medical leave of absence.
01/2011
Standard Authorization Form and other HIPAA Privacy Forms 
Protected health information (PHI) is defined by privacy rules enacted under the Health Insurance Portability and Accountability Act (HIPAA). BCBSOK plan members can use privacy forms to authorize BCBSOK to disclose their PHI.
07/2022