Blue Access for Producers

Downloadable Forms for Mid-Market Groups (51-150 Employees)


Here are some commonly used forms for conducting business with Blue Cross and Blue Shield of Illinois (BCBSIL). Non-regulated cases with 51 or more total employees on average over the prior calendar year including all eligible and ineligible employee types such as temporary, union, seasonal, and part-time employees. This Includes employees of controlled/affiliated entities and domestic parent companies.

To access more downloadable forms, please log in to Blue Access for Producers. To review and sign your request now electronically, select the sign now option below. Or you can download and save the form, to review and sign at a later date.


New Business/Enrollment Forms

Form Name Digital Form Download
2019 Enrollment Package includes Benefit Program Application (BPA), Benefit Plan Selection (BPS) Form, MSP Form, and Artifacts Documentation (for effective date 6/1/2019 and prior) sign now External Link N/A
2019 Enrollment Package includes Benefit Program Application (BPA), Benefit Plan Selection (BPS) Form, MSP Form, and Artifacts Documentation (for effective date 7/1/19 and after) sign now External Link N/A
2019 Benefit Program Application (BPA) Form – For new accounts effective 1/1/2019 and after sign now External Link download form Word Document
download form Acrobat PDF
2019 Benefit Plan Selection (BPS) Form – For new accounts effective 7/1/2019 and after sign now External Link download form Word Document
download form Acrobat PDF
2019/2018 Benefit Plan Selection (BPS) Form – For new accounts effective 1/1/2018 through 6/30/2019 sign now External Link download form Word Document
download form Acrobat PDF
2019/2018 Group Enrollment Application/Change Form – Use this form to apply for group coverage effective 1/1/2019, or to make changes to an existing BCBSIL policy sign now External Link download form Acrobat PDF
2019/2018 Group Enrollment Application/Change Form – Spanish N/A download form Acrobat PDF
Illinois Extension Form sign now External Link download form Acrobat PDF
HMO/CPO Provider Selection Enrollment and Change Form N/A download form Acrobat PDF
Employer Group Information (EGI) Form – This form must be submitted with the BPA sign now External Link download form Acrobat PDF
Mid-Market New Business Checklist for State Area Brokers N/A download form Acrobat PDF
Mid-Market New Business Checklist for Chicago Metro Brokers N/A download form Acrobat PDF
Smart Census Import Tool Version 8
(To obtain a copy of the tool, please log in to Blue Access for Producers.)
N/A N/A
Enrollment Census Template
(For use with Excel 2009 and older versions; file must be saved before entering data)
N/A download form Excel Document
Full-Time Status Certification for Owners, Partners, Proprietors sign now External Link download form Word Document
Affidavit of Domestic Partnership sign now External Link download form Acrobat PDF
BlueTrack Process Flier N/A download flier Acrobat PDF
Mid-Market Initial Premium EFT Payment Form sign now External Link download form Acrobat PDF

 

Renewal Forms

Form Name Digital Form Download
2019/2018 Group Enrollment Application/Change Form – Use this form to apply for group coverage effective 1/1/2019, or to make changes to an existing BCBSIL policy sign now External Link download form Acrobat PDF
2019/2018 Group Enrollment Application/Change Form – Spanish N/A download form Acrobat PDF
Addendum to the Insured BPA Regarding Affiliated Companies sign now External Link download form Word Document

 

BlueCare PPO Dental Forms

Form Name Digital Form Download
2019/2018 Group Enrollment Application/Change Form – Use this form to apply for group coverage effective 1/1/2019, or to make changes to an existing BCBSIL policy sign now External Link download form Acrobat PDF
2019/2018 Group Enrollment Application/Change Form – Spanish N/A download form Acrobat PDF

 

BlueCare HMO Dental Forms

Form Name Digital Form Download
2019/2018 Group Enrollment Application/Change Form – Use this form to apply for group coverage effective 1/1/2019, or to make changes to an existing BCBSIL policy sign now External Link download form Acrobat PDF
2019/2018 Group Enrollment Application/Change Form – Spanish N/A download form Acrobat PDF
HMO/CPO Provider Selection Enrollment and Change Form N/A download form Acrobat PDF

 

Claim Forms

Form Name Digital Form Download
Dental Claim Form N/A download form Acrobat PDF
Medical Claim Form (Domestic) – Members should use this form to request reimbursement for health care services obtained within the United States, a U.S. territory, when on a cruise ship, or on a U.S. military base. N/A download form Acrobat PDF
Medical Claim Form (Domestic) – Spanish N/A download form Acrobat PDF
Medical Claim Form (International) – Members should use this claim form to request reimbursement for health care services obtained when traveling internationally – when outside of the United States or a U.S. territory, but NOT for services obtained on a cruise ship or a U.S. military base. N/A download form Acrobat PDF
Medical Claim Form (International) – Spanish N/A download form Acrobat PDF
Prime Prescription Drug Claim Form N/A download form Acrobat PDF

 

Medicare Secondary Payer (MSP) Forms and Information

Form Name Digital Form Download
Annual Medicare Secondary Payer (MSP) Employer Acknowledgement Form with Instructions N/A download form Acrobat PDF
Information Regarding Medicare as Secondary Payer Statute N/A download flier Acrobat PDF
MSP Fact Sheet N/A download flier Acrobat PDF

 

Prescription Drug Forms

Form Name Digital Form Download
Prime Prescription Drug Claim Form N/A download form Acrobat PDF
PrimeMail® Prescription Order Form N/A download form Acrobat PDF
Women's Contraceptive Coverage List N/A download list Acrobat PDF

 

Miscellaneous

Form Name Digital Form Download
Small Group HCSC/FDL Disclosure Form N/A download form Acrobat PDF
IL Employee Continuation Privilege Election Form N/A download form Acrobat PDF
IL Continuation Group Request Form N/A download form Acrobat PDF
Statement of Termination of Domestic Partnership N/A download form Acrobat PDF
Tax Information on Health Benefits for Domestic Partnership N/A download form Acrobat PDF
Producer of Record Transfer Form and Instructions N/A download form Acrobat PDF

 

Legal / HIPAA Forms

Form Name Digital Form Download
Standard Authorization Form and other HIPAA Privacy Forms N/A N/A