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 |
07/2018 |
| 07/2018 | |
2022 Enrollment Package for Small Groups 2-50 |
10/2021 |
| 2023 Benefit Program Application (BPA) for Small Groups 2-50 2023 Benefit Program Application (BPA) for Small Groups 2-50  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 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 |
06/2021 |
2022 Benefit Program Application (BPA) Amendment for Small Groups 2-50 |
06/2021 |
2023 Benefit Program Application (BPA) for Mid-Market Groups 51-150 |
10/2022 |
2023 Benefit Program Application (BPA) Amendment for Mid-Market Groups 51-150 |
10/2022 |
2022 Benefit Program Application (BPA) for Mid-Market Groups 51-150 |
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 |