Group Forms
Group Forms | Blue Cross and Blue Shield of Illinois | Humana
IAC | Starmark | Time | Trustmark | UnitedHealthcare
   
 
Enrollment Kit as One File
Blue Cross Blue Shield Full Enrollment Kit (6/01/08)
 
Enrollment Kit as Separate Forms
Producer/Employer New Business Checklist (20910 3/07)
Employee Application (20086 9/06)
Disclosure Form (EB4644 3/04)
Employer Group Information Form (20561 8/05)
Benefit Plan Selection Form (4/08) PDF
Benefit Plan Selection Form (4/08) Fillable Word Doc
Sample Broker of Record Letter (EB5063 5/01)
Benefit Program Application (New Case Submissions 2-150)
Medicare Secondary Payer Form (new business)
 
Additional Forms Not Included in the Enrollment Kit
Addendum to the Insured BPA Reguarding Affiliated Companies (MGA-10-1-ADD 2007 )
Spanish directions for the Small Group Employee Application (20535 07/04)
HIPAA Notice of Privacy Practices (20693 06/05)
General Notice of Special Enrollment Rights & Preexisting Condition Exclusion (20742 07/05)
Affidavit of Domestic Partnership (20551 01/05)
 
Administrative Forms for "in force" Groups
Enrollment Change Request Form (EB4633 11/03)
Cobra Notification Form
Cobra Election Form
BCBS Shortened BPA
Medical Claim Form
International Claim Form (N13-04-086)
Student Certification Form
Member PHI Release Form
Medicare Secondary Payer Form (in force)
BlueAccess For Employers Enrollment Form (Groups 2-50)
BlueAccess For Employees Enrollment Form (Groups 51+)
Benefit Plan Selection Form (Benefits Plan Changes 2-150)1/1/2008 effective dates and after
MSP Letter and Producer Notice IL
Statement of Termination of Domestic Partnership (20560 2/07)
Tax Information on Health Benefits for Domestic Partnership (20559 2/07)
 
Prescription Drug Forms
Mail Service Prescription Drug Program Brochure (20158 2/06)
PrimeMail Non-HMO and HMO 90-Day Supply-Mail Service Order Form (20161 1/06)
PrimeMail Physician Fax Form (2560IL 2/05)
HMO 90-Day Supply Mail Service ONLY – Walgreens Mail Service Physician Fax Form (10/07)
Rx Drug Card and Fully Integrated BlueSCRIPT – Claim Form (20157 1/06)
BlueScript Electronic Claim Service – Claim Form (01103 12/06)
 
Blue Cross and Blue Shield of Illinois - An Independent Licensee of the Blue Cross and Blue Shield Association