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Group Forms

PW_B147973
 
Table of Contents 
Small Group (2 to 50 Employees)
Large Group (51 or more Employees)
Claims
COBRA
HIPAA
Miscellaneous
 

Small Group (2 to 50 Employees)

Member Applications  
Combined Medical Questionnaires
Dental Prime and Dental Complete Broker Services
Dental Prime and Dental Complete Employer Services
Enrollment Eligibility Checklist
Member Enrollment Application Tips
Member Enrollment Form - Small/Large Group, 2-99 employees
Member Enrollment Form - Small/Large Group, 2-99 employees - Printed version*
Member Enrollment Form - Small/Large Group, 2-99 employees - Fillable version*

*Effective 4/1/2012 - For ASO groups use only

 
 
Member Change  
Cancellation Form - Small Group
Member Enrollment Change Form
Member Enrollment Change Form - Printed Version*
Member Enrollment Change Form - Fillable Version*

*Effective 4/1/2012 - For ASO groups use only

 
 
Group Application  
Group Commission Agreement – Single Case
Group Enrollment Checklist
Group Insurance Enrollment Form
Group Master Application form: Group Applications for POS, POS, PPO, CMM, Dental and/or Vision coverage
 
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Large Group (51 or more Employees)

Member Applications  
Dental Prime and Dental Complete Broker Services
Dental Prime and Dental Complete Employer Services
Member Enrollment Form - Large Group, 51-99 Employees
Member Enrollment Application – Large Group, 100+ Employees
Member Enrollment Application - Small/Large Group, 2-99 Employees
Member Enrollment Application – Large Group, 100+ Employees - Printed version*
Member Enrollment Application – Large Group, 100+ Employees - Fillable version*
Member Enrollment Application - Small/Large Group, 2-99 Employees - Printed version*
Member Enrollment Application - Small/Large Group, 2-99 Employees - Fillable version*

*Effective 4/1/2012 - For ASO groups use only

 
 
Member Change  
Change of Coverage Application – Large Group
Cancellation Authorization Form – Large Group
Member Enrollment Change Form
Member Enrollment Change Form - Printed Version*
Member Enrollment Change Form - Fillable Version*

*Effective 4/1/2012 - For ASO groups use only

 
 
Group Application  
Group Enrollment Checklist (51-99)
Group Enrollment Checklist (100+)
Georgia Enrollment and Billing Macro Spreadsheet
Group Master Application form: Group Applications for POS, POS, PPO, CMM, Dental and/or Vision coverage
Member Enrollment Application Tips (51-99)
Member Enrollment Application Tips (100+)
Macro Master Copy Enrollment Tool
 
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Claims

BlueCard Worldwide International Claim Form
BlueCard Worldwide International Claim Form (en Español)
Dental Claim Form
Dental Prime and Dental Complete Claim Form
Dependent Care Claim Form
Health Care Claim Form
Prescription Drug Claim Form
To find this form, members must visit the Express Scripts website after login to their health plan site. Click the link in the Refill a Prescription section after login. On the Express Scripts site, select the Claims Reimbursement Form from the Printable Forms section.
 
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COBRA

COBRA Administration Services Guide
COBRA Administration Overview
COBRA General Notice Questionnaire
COBRA General Rights Notification Instructions and Layout
COBRA Implementation Instruction Guide
COBRA Implementation Paperwork
COBRA Notice of Qualifying Event
COBRA Rate Sheet
COBRA Takeover Continuant Notification Form
Employer COBRA Webcast Training
 
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HIPAA

Conditioned Authorization Form
Conditioned Authorization Form - Instructions
 
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Miscellaneous

Certificate of Dependency Form
Chase – WellPoint HSA Admin Reference Guide
Complete Choice Enrollment Form
Dependent Care Spending Account Claim Form
Direct Deposit Form
EET Eligibility Status Verification Form
Employer Reference Guide Order Form – Small Group
EAP BCBSGa Plan Design and Rate Sheet
Employee Assistance Program (EAP) Application
Enrollment Eligibility Checklist
Flexible Benefits Enrollment Guide
FSA Banking Information Packages
Group Single Case Commission Agreement
Handicapped/Disabled Member Certification
Handicapped/Disabled Member Dependent Determination
Health Reimbursement Account (HRA) / Flexible Spending Accounts (FSA)
HMC Products Purchased
HSA Group Initiation Form
HSA Health Care Spending Claim Form
HSA Application Group- 2010
HSA Application Individual – 2010
Internet Eligibility Agreement
Large Group Supply Order Form
Life & Disability Forms
Macro Spreadsheet Q & A
Open a New Account with JP Morgan Chase Bank
Statement of Chamber Membership
Supply Request Form – Large Group
Third Party Agreement
Username Policy and Usage Agreement
Your Guide To Flexible Spending Accounts
 
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Blue Cross and Blue Shield of Georgia, Inc. and Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. are independent licensees of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.