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
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) - Authorization for the Release of Protected Health Information (PHI) relating to Substance Use Disorder *
(form 29-456A) - Revocation of Authorization for the Release of Protected Health Information (HIPAA Form) *
(Form 29-457) - 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) - 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 - Health Profile *
(Form MC547) - 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)
* 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) - 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) - 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