Form Name |
Digital Form |
Download |
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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 Enrollment Package – includes Benefit Program Application (BPA), EGI Form, and Artifacts Documentation for new accounts effective 1/1/23 and after |
sign now |
N/A |
2023 Benefit Program Application (BPA) for Small Groups 2-50 – for new accounts effective on or after 1/1/2023 |
sign now |
download form 
download form |
2023 Benefit Program Application (BPA) Amendment for Small Groups 2-50 – for renewing accounts with anniversary dates on or after 1/1/2023; use this form to amend the original BPA |
sign now |
download form 
download form |
Employer Group Information (EGI) Form – this form must be submitted with the BPA |
N/A |
download form |
2022 Enrollment Package – includes Benefit Program Application (BPA), EGI Form, and Artifacts Documentation for new accounts effective 1/1/22 and after |
sign now |
N/A |
2022 Benefit Program Application (BPA) for Small Groups 2-50 – for new accounts effective on or after 1/1/2022 |
sign now |
download form 
download form |
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 |
sign now |
download form 
download form |
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 |
Group Employer Medical Questionnaire |
N/A |
download form |
Request for Continuation Coverage |
N/A |
download form |
Request for Proposal Census Form |
N/A |
download form |
Request for Proposal |
N/A |
download form |
Supplemental Employment Verification Form |
sign now |
download form |
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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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 integration with BenefitWallet.
|
N/A |
download form |
HSA Employer Setup Form – Flex – Submit an electronic copy of this form for each employer wishing to elect HSA integration with Flex.
|
N/A |
download form |
FSA Employer Setup Form – Flex – Submit an electronic copy of this form for each employer wishing to elect FSA integration with Flex.
|
N/A |
download form |
HSA/FSA Employer Setup Form – HealthEquity® – Submit an electronic copy of this form for each employer wishing to elect HSA and/or FSA integration with HealthEquity.
|
N/A |
download form |
HSA/FSA Employer Setup Form – HSA Bank® – Submit an electronic copy of this form for each employer wishing to elect HSA and/or FSA integration with HSA Bank.
|
N/A |
download form |
Consumer Directed Health Accounts Enrollment and Change Form – Use this form to collect employee FSA elections if sending enrollment through BCBSOK to BenefitWallet, HealthEquity or HSA Bank.
|
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 |