Forms and manuals

Manuals

Group Administration Manual (GAM) 
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, summary of benefits and coverage details and much more.

• Enrollment Eligibility Date Calculator
• New Hire Checklist
• Employee Termination Checklist
• Required Disclosures for Group Health Plans
• eBilling User Guide - Special Funded Groups
• CMS Creditable Coverage Disclosure

Online forms

• Address change form
• Explanation of benefits (EOB) order form
• ID card order form

Miscellaneous forms

Navigate to the Adobe website to download the latest version of Acrobat Reader. Version 9.0 or higher is required.

• Application for Plan 150 Cancer Only Plan and Hospital Indemnity Plan (HIP) * 
  (Form 5-14/105A)
• Application and brochure for Secure 300 / Secure HIP 
  (Form 5-26)
• Application for Secure 300 / Secure HIP application * 
  (Form 5-26A)
• Authorization for Release of Protected Health Information (HIPAA Form) * 
  (Form 29-456)
  • Spanish Version *
• Authorization for the Release of Protected Health Information (PHI) relating to Substance Use Disorder * 
  (form 29-456A)
  • Spanish Version *
• Revocation of Authorization for the Release of Protected Health Information (HIPAA Form) * 
  (Form 29-457)
  • Spanish Version *
• Automatic Payment Authorization * 
  (Form MC806B)
• Banking Change Form (for Self-Funded employers) * 
  (Form 84-5)
• Billing Worksheet * 
  (Form 5-5)
• Change Form for Group Coverage * 
  (Form 29-151)
  • Spanish Version *
• CMS SSN Declination Form (offsite link)
• Continuation Coverage Rights Under COBRA Election Notice Template (offsite link)
• Continuation Coverage Rights Under COBRA General Notice Template (offsite link)
• Application for Coverage of Dependent With Disabilities * 
  (Form 15-411)
• Dependent Child Affidavit * 
  (Form 29-158)
• Duplicate Coverage Questions * 
  (Form 34-705)
• Enrollment Form for Group Coverage * 
  (Form 40-127) 
  Please also complete life insurance applications if applicable: Life Insurance Forms
  • Spanish Version *
• Health Profile * 
  (Form MC547)
  • Spanish Version *
• HIPAA Designation Form * 
  (Form MC280)
• Home Delivery Order Form (Mail Order Form) (offsite link)
• USERRA Election Form * 
  (Form 29-297)
• Waiver of Enrollment * 
  (Form 40-106)
  • Spanish Version *

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

Claim forms

• Blue Cross Blue Shield Global Core Claim Form (offsite link)
• Cancer Plan Claim Form * 
  (Form 29-134)
• Claim Appeal Form * 
  (Form 34-730WEB)
  • Spanish version *
• Claim Appeal Representative Authorization Form * 
  (Form 29-58)
• Hospital Indemnity Plan Claim Form * 
  (Form 29-142)
• Member Claim Form * 
  Use this form to submit a claim for a prescription drug charge for any BlueRx product, excluding BlueRx Direct. 
  (Form 34-4)
  • Spanish version *
• Prescription Drug Claim Form (Prime Therapeutics) * 
  Use this form to submit a claim for a prescription drug charge if you have BlueRx Direct. 
  (Form 34-148)

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

Further (formerly SelectAccount) forms and guides

• FSA Plan Design Guide * 
  (Form X22002)
• HRA Plan Design Guide * 
  (Form X22003)
• HRA Enrollment * 
  (Form X21988)
• HSA Plan Design Guide * 
  (Form XX22001)
• HSA Application * 
  (Form X21989)
• HSA Reference Guide 
  (Form X22000)

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

Advance Insurance Company of Kansas (AICK)

• Visit the AICK forms page for all Advance Insurance forms.