Forms & Manuals
-
Address Change Form
- ID Card Order Form
- Primary Care Physician (PCP) Change Form
- Summary of Claims Processed (SOCP) Order Form
You can find the CMS Creditable Coverage Disclosure Web page at http://www.cms.hhs.gov/creditablecoverage. On the left-hand column, you'll find useful links that can take you to the Disclosure to CMS Form. You will also find links that provide you the model disclosure language for Beneficiary Creditable and Non-Creditable Coverage to be used after February 15, 2007.
The following forms were created with Adobe Acrobat. Visit the Adobe Web site to download the latest version of Acrobat Reader.
Miscellaneous Forms
- Authorization
for Release of Protected Health Information (HIPAA Form) *
(Form 29-456) - Automatic
Payment Authorization *
(Form MC806B) - Banking Change Form (for Self-Funded employers) *
(Form 84-5) - Change Form for Group Coverage
(Form 29-151) - Change Form (For
employers with 1-9 employees) *
(Form 29-462) - COBRA Active Participant
Form *
(Form 40-27) - Continuation Coverage
Rights Under COBRA Template
(Microsoft Word file) - Continuation of
Group Health Coverage (COBRA) Application *
(Form 29-298) - Coverage of Handicapped
Dependent Child Application *
(Form 15-411) - Dependent Child Affidavit *
(Form 29-158) - Employee Payroll Withholding
Authorization
(Form MC818) - Enrollment Form for Group Coverage
(formerly Coverage Application/Group Coverage) *
(Form 40-127) Please also complete life insurance applications if applicable: Life Insurance Forms - General Notice of Pre-Existing Condition Exclusion
(Microsoft Word file) - Health Profile (for groups with 1-9 employees)*
(Form MC547) - HIPAA Designation Form *
(Form MC280) - HIPAA Designation Form (for groups with a privacy officer) *
(Form MC280a) - MSP-COBRA Selection Form *
(Form 5-19) - MSP-COBRA Selection
Form (employee's spouse) *
(Form 5-19a) - OPL Questionnaire
- USERRA
Election Form
(Form 29-297) - Waiver of Enrollment *
(Form 40-106)
- Business
Administrator Supplies Order Form
(Online form) - Group Administration Supplies Order Form
(Online form)
* You may fill out and print this form using your acrobat reader program.
Claim Forms
- Blue Select Claim Form
(Form 29-303) - BlueCard Worldwide International
Claim Form
- Claim Appeal Form
(Form 34-730) - Claim Appeal Representative
Authorization Form
(Form 29-58) - Drug Claim Form
(Form 34-275) - Hospital Indemnity Plan Claim Form
(Form 29-142) - Member Claim Form (to be used when submitting both medical and drugs)
(Form 34-4) * - Plan 150 Claim Form
(Form 29-134) - Premier Blue Member Claim Form
(Form 87-12) - Prescription Drug
Claim Form (Prime Therapeutics)
(Use this form to submit a claim only if you have BlueRx Direct.)
(Form 34-148) - PrimeMail Order Form
- PrimeMail Refill Order Form
- Qualified Medical Child
Support Claim Form
(Form 34-438) - Qualified Medical Child
Support Claim Form - BlueRx
(Form 34-246) - State of Kansas Employee Claim Form
(Form 34-441)
* You may fill out and print this form using your acrobat reader program.
Manuals
Business
Administrator Guide
(PDF, 947k - updated 08/08)
This manual is designed for business-billed individual plans. On
your identification card, you will see the number beginning with
M00. This guide contains valuable information to help you with the
administration of your First Choice benefits package. It provides
important telephone numbers and easy-to-read explanations about
insurance for busy business owners.
Group Administration Manual
(PDF, 3.9MB - updated 07/08)
This manual is designed to give you the valuable information you
need to administer your insurance benefit package. It includes address
and telephone numbers, answers to common questions, an explanation
of state and federal laws regarding continuation coverage, sample
applications and other useful forms and information.
eBilling User Guide - Special Funded Groups
(PDF, 1.6MB - updated 03/08)