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

06/2021

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

06/2021
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.
04/2013
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 a prescription drug purchase. They must submit the original pharmacy receipt with the completed form. 01/2016
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 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. 05/2015
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. 08/2019
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. 04/2018