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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 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 First Choice Coverage (For employers with 1-9 employees) *
  (Form 29-462)
• Change Form for Group Coverage
  (Form 29-151)
• COBRA Active Participant Form *
  (Form 40-27)
  • Attestation Form (Use when seeking treatment as an assistance eligible individual as related to the American Recovery and Reinvestment Act of 2009) *
    (Form 40-24)
• 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)
• Declination to Provide Social Security Number *
  (Form MC109)
• 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
  • Spanish Version
    
• 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

• 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)
• 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.

SelectAccount Forms/Guides

• FSA Plan Design Guide
• HRA Plan Design Guide
• HRA Enrollment
• HSA Plan Design Guide
• HSA Application

 

Manuals

Business Administrator Guide
(PDF, 947k - updated 12/08) 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, 2.3 MB - updated 09/09) 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 03/09)