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 #
606465.1022 2023 Individual Paper Application Checklist N/A
73447.1022 2023 Health Application/Change in Coverage – Use this health application for 2023 plans effective January 1, 2023. N/A
600001.1022 2023 Dental Application/Change in Coverage – Use this dental application for 2023 plans effective January 1, 2023. N/A
601673.1022 2023 Individual Paper Application Overflow Page N/A
606465.1021 2022 Individual Paper Application Checklist N/A
73447.1021 2022 Health Application/Change in Coverage – Use this health application for 2022 plans effective January 1, 2022. N/A
600001.1021 2022 Dental Application/Change in Coverage – Use this dental application for 2022 plans effective January 1, 2022. N/A
601673.1021 2022 Individual Paper Application Overflow Page N/A
Stock # / Date

Account Maintenance Forms

Oklahoma Form #
72008.0222 Auto Bill Pay - Automatic Premium Payment Authorization Agreement N/A
600901.1018 Auto Bill Pay - Automatic Premium Payment Authorization Agreement - Spanish N/A
608020.0622 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. Mail or fax the completed form to BCBSOK (see address and fax number at the top of the form). N/A
Stock # / Date

Legal / HIPAA Forms

Oklahoma Form #
07.01.22 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
Stock # / Date Legal / HIPAA Forms Oklahoma Form #
07.01.22 Standard Authorization Form and other HIPAA Privacy Forms N/A