Downloadable Forms for Mid-Market Groups (51-150 Employees)

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.

To review and sign your request now electronically, select the sign now option below. Or you can download and save the form, to review and sign at a later date.

Enrollment Forms and Change Forms

Form Name Digital Form Download
Group Enrollment Application/Change Form – use this form to apply for group coverage or to make changes to an existing BCBSOK policy sign now download form
Group Enrollment Application/Change Form – Spanish N/A download form
2023 Benefit Program Application (BPA) for Mid-Market Groups 51-150 – For new and renewing accounts effective 1/1/2023 or after N/A download form Word Document
download form
2023 Benefit Program Application (BPA) Amendment for Mid-Market Groups 51-150 – For renewing accounts with anniversary dates on or after 1/1/2023; use this form to amend the original BPA sign now download form Word Document
download form
Employer Group Information (EGI) Form – this form should be submitted with the BPA N/A download form

Benefit Wallet® Benefits Design Guide for FSA, HRA and Commuter Spending Accounts – Submit an electronic copy of this form for each employer wishing to elect FSA and/or HRA integration with BenefitWallet.

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Checklist for Obtaining a Quote for New Groups 51-150 N/A download form
Checklist for Submitting Sold Non-Regulated Groups 51-150 N/A download form

Consumer Directed Health Accounts Enrollment and Change Form – Use this form to collect employee FSA and/or HRA elections if sending enrollment through BCBSOK to BenefitWallet, HealthEquity or HSA Bank.

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Deductible Credit Form for Employees at Enrollment N/A download form
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. Mail or fax the completed form to BCBSOK (see address and fax number at the top of the form). You can also use this form to add a disabled dependent to a new policy (include this completed form when you submit your enrollment application). N/A download form

FSA Employer Setup Form – Flex – Submit an electronic copy of this form for each employer wishing to elect FSA and/or HRA integration with Flex.

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HSA Employer Setup Form – Benefit Wallet® – Submit an electronic copy of this form for each employer wishing to elect HSA integration with BenefitWallet.

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HSA Employer Setup Form – Flex – Submit an electronic copy of this form for each employer wishing to elect HSA integration with Flex.

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HSA/FSA Employer Setup Form – HealthEquity® – Submit an electronic copy of this form for each employer wishing to elect HSA, FSA and/or HRA integration with HealthEquity.

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HSA/FSA Employer Setup Form – HSA Bank® – Submit an electronic copy of this form for each employer wishing to elect HSA, FSA and/or HRA integration with HSA Bank.

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Request for Continuation Coverage N/A download form
Smart Census Import Tool
(To obtain the latest Version of the tool, please log into Blue Access for Producers).		 N/A N/A

 

Renewal Forms and Information

Form Name Digital Form Download
2023 Important Benefit Changes/Uniform Modification Notice - Identifies some of the most important benefit plan changes for the 2023 - 2024 coverage year. N/A download form
Medical Loss Ratio (MLR) Written Assurance Form - Complete this standalone form only for an existing group if one of these conditions applies: 1) the group is changing Church designation as defined by the IRS, or 2) it is a Church group wanting to change how the rebate is handled. sign now download form
Average Employee Count (AEC) Form sign now download form

 

Medicare Secondary Payer (MSP) Form and Information

Form Name Digital Form Download
Annual MSP Employer Acknowledgement Form (EAF) with Instructions on Completing the Form sign now download form
Information Regarding the MSP Statute N/A download flier
MSP Fact Sheet N/A download fact sheet

 

Miscellaneous Forms

Form Name Digital Form Download
Affidavit of Domestic Partnership sign now download form
Common Law Marriage Affidavit N/A download form
Request to Extend Coverage for Disabled Dependent sign now download form

 

Legal / HIPAA Forms

Form Name Digital Form Download
Standard Authorization Form and other HIPAA Privacy Forms N/A N/A