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Forms & Manuals

• Address Change Form
• ID Card Order 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 Jan. 1, 2009.

The following forms were created with Adobe Acrobat. Visit the Adobe Web site to download the latest version of Acrobat Reader. Version 9.0 or higher is required.

Manuals

Business Administrator Guide
(PDF, 1.46MB - updated 04/10) 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.

New! Group Administration Manual
The redesigned, easy-to-use GAM keeps you on top of the latest administrative and legislative topics. The manual includes links to applications and forms, a qualifying events chart, billing information and much more.

• Enrollment eligibility date calculator
  
  

eBilling User Guide - Special Funded Groups
(PDF, 1.6MB - updated 03/09)

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 First Choice Coverage *
  (Form 29-462)
• Change Form for Group Coverage
  (Form 29-151)
  • Spanish Version
• 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)* – for print only
  
  • Spanish Version
  Please also complete life insurance applications if applicable: Life Insurance Forms
• General Notice of Pre-Existing Condition Exclusion
• 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)
• Duplicate Coverage Questions
  (Form 34-705)
• 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)
• New Hire Checklist
• Employee Termination Checklist
• Government Mandate

* You may fill out and print this form using your acrobat reader program.

Claim Forms

• BlueCard Worldwide International Claim Form
  
• Claim Appeal Form
  (Form 34-730)
  • Spanish version
• Claim Appeal Representative Authorization Form
  (Form 29-58)
• Hospital Indemnity Plan Claim Form
  (Form 29-142)
• Member Claim Form *
  (Form 34-4)
• Plan 150 Claim Form
  (Form 29-134)
• 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
  

* You may fill out and print this form using your acrobat reader program.

SelectAccount Forms/Guides

• FSA Plan Design Guide *
  (Form F3987)
• HRA Plan Design Guide *
  (Form F7927)
• HRA Enrollment *
  (Form F7988)
• HSA Plan Design Guide *
  (Form F7386)
• HSA Application *
  (Form F9158)

* You may fill out and print this form using your acrobat reader program.