Blue Access for Producers

Downloadable Forms for Large Groups (151+ Employees)


Here are some commonly used forms for conducting business with Blue Cross and Blue Shield of Illinois (BCBSIL). The forms provided in this section are applicable to groups with 151+ enrolled lives.

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.


New Business/Enrollment Forms for PPO/Non-HMO

Form Name Digital Form Download
2019/2018 Group Enrollment Application/Change Form – use this form to apply for group coverage effective 1/1/2019, or to make a change to an existing BCBSIL policy sign now External Link download form Acrobat PDF
2019/2018 Group Enrollment Application/Change Form – Spanish N/A download form Acrobat PDF
Addendum to the Insured BPA Regarding Affiliated Companies sign now External Link download form Word Document
Affidavit of Domestic Partnership sign now External Link download form Acrobat PDF
Full-Time Status Certification for Owners, Partners, Proprietors sign now External Link download form Word Document

 

New Business/Enrollment Forms for HMO (BlueAdvantage HMO and HMO Illinois)

Form Name Digital Form Download
2019/2018 Group Enrollment Application/Change Form – use this form to apply for group coverage effective 1/1/2019, or to make a change to an existing BCBSIL policy sign now External Link download form Acrobat PDF
2019/2018 Group Enrollment Application/Change Form – Spanish N/A download form Acrobat PDF
Addendum to the Insured BPA Regarding Affiliated Companies sign now External Link download form Word Document
Affidavit of Domestic Partnership sign now External Link download form Acrobat PDF

 

BlueCare PPO Dental Forms

Form Name Digital Form Download
2019/2018 Group Enrollment Application/Change Form – use this form to apply for group coverage effective 1/1/2019, or to make a change to an existing BCBSIL policy sign now External Link download form Acrobat PDF
2019/2018 Group Enrollment Application/Change Form – Spanish N/A download form Acrobat PDF

 

BlueCare HMO Dental Forms

Form Name Digital Form Download
2019/2018 Group Enrollment Application/Change Form – use this form to apply for group coverage effective 1/1/2019, or to make a change to an existing BCBSIL policy sign now External Link download form Acrobat PDF
2019/2018 Group Enrollment Application/Change Form – Spanish N/A download form Acrobat PDF

 

Claim Forms

Form Name Digital Form Download
Dental Claim Form N/A download form Acrobat PDF
Medical Claim Form (Domestic) – Members should use this form to request reimbursement for health care services obtained within the United States, a U.S. territory, when on a cruise ship, or on a U.S. military base. N/A download form Acrobat PDF
Medical Claim Form (Domestic) – Spanish N/A download form Acrobat PDF
Medical Claim Form (International) – Members should use this claim form to request reimbursement for health care services obtained when traveling internationally – when outside of the United States or a U.S. territory, but NOT for services obtained on a cruise ship or a U.S. military base. N/A download form Acrobat PDF
Medical Claim Form (International) – Spanish N/A download form Acrobat PDF
Prime Prescription Drug Claim Form N/A download form Acrobat PDF

 

Medicare Secondary Payer (MSP) Forms and Information

Form Name Digital Form Download
Annual Medicare Secondary Payer (MSP) Employer Acknowledgement Form with Instructions N/A download form Acrobat PDF
Information Regarding Medicare as Secondary Payer Statute N/A download flier Acrobat PDF
MSP Fact Sheet N/A download flier Acrobat PDF

 

Prescription Drug Forms

Form Name Digital Form Download
Prime Prescription Drug Claim Form N/A download form Acrobat PDF
PrimeMail® Prescription Order Form N/A download form Acrobat PDF

 

Miscellaneous

Form Name Digital Form Download
IL Employee Continuation Privilege Election Form N/A download form Acrobat PDF
IL Continuation Group Request Form N/A download form Acrobat PDF
Statement of Termination of Domestic Partnership N/A download form Acrobat PDF
Tax Information on Health Benefits for Domestic Partnership N/A download form Acrobat PDF

 

Legal / HIPAA Forms

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