Blue Access for Producers
 

Downloadable Forms for Large Group 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®. Other Adobe accessibility tools and information can be downloaded at access.adobe.com .

LARGE GROUP FORMS (Groups of 151+)
Stock # / Date Large Group - Enrollment Forms and Change Forms Oklahoma Form #
OKBPA151Plus (rev. 07.15) 2016 Benefit Program Application (BPA) for New Groups 151+  – for accounts effective on or after 1/1/2016 N/A
OKBPA151PlusRA (rev. 11.14) 2016 Benefit Program Application (BPA) Amendment for Groups 151+  – for renewing fully insured accounts with anniversary dates on or after 1/1/2016; use this form to amend the original BPA N/A
HCSC OK GEN ASO BPA-A (Rev. 11/15) 2016 Benefit Program Application (BPA) for ASO Groups 151+  – for renewing ASO accounts with anniversary dates on or after 1/1/2016; use this form to amend the original BPA N/A
OKBPA151Plus 2015 Benefit Program Application (BPA) for New Groups 151+  – for accounts effective on or after 1/1/2015 N/A
OKBAP151PlusRA 2015 Benefit Program Application (BPA) Amendment for Existing Groups 151+  – for existing accounts enrolled on or after 1/1/2015; use this form to amend the original BPA N/A
-- BlueSelect Voluntary Group Dental Contract 151+  N/A
71856.0211 Checklist for Obtaining a Quote for New Groups 151+  N/A
72317.0811 Checklist for Submitting Sold Groups 151+  N/A
601863.0814 Enrollment Application/Change Form  N/A
602488.0115 Enrollment Application/Change Form - Spanish  N/A
-- Deductible Credit Form for Employees at Enrollment  N/A
71268.1010 Request for Continuation Coverage  N/A
 
Stock # / Date Large Group - Miscellaneous Forms Oklahoma Form #
600844.0114 Affidavit of Domestic Partnership  N/A
10.290 (07/06) Common Law Marriage Affidavit  N/A
602661.0315 Disabled Dependent Certification Form  N/A
 
Stock # / Date Medicare Secondary Payer (MSP) Form and Information Oklahoma Form #
21126.0913 Annual MSP Employer Acknowledgement Form with Instructions on Completing the Form N/A
21094.0609 Information Regarding the Medicare as Secondary Payer Statute N/A
72875.0612 MSP Fact Sheet N/A
 
Stock # / Date Legal / HIPAA Forms Oklahoma Form #
08.01.15 Standard Authorization Form and other HIPAA Privacy Forms N/A