BlueCross BlueShield of Georgia

BCBSGA

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What is BCBSGa's 360° Health® program?

A total-health solution that surrounds everyone with the help they need to live healthier, feel better and save money doing it.

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PW_E167926

Post-sale questions? Call Employer Services, a division of Customer Service, at 877-567-1799.

These forms apply to group only, unless noted with an *, which indicates form applies to group and individual coverage.

Dental Prime and Dental Complete Tools

Broker Rate Calculator

Broker Rate Calculator – Password Request Form

Online Commission Reports Tool*

Online Commission Reports User Request Form*

ACH Commission Form*

Agent of Record Assignment

Pre-Sale Materials

Plan Designs (Groups 2-50)

Plan Designs (Groups 51+)

Group Implementation & Enrollment

Group Master Application with Submission Requirement Checklist (for groups 2-50)

Census Enrollment Spreadsheet

Member & Group Forms

Membership Enrollment Form

Membership Enrollment Form – Spanish

Membership Maintenance Form

Authorization to Release Information*

Authorization to Release Information - Spanish*

HIPAA Designated Contact Form

Disabled Dependent/Michelle’s Law Application*

Claims & Additional Benefits Forms

Dental Claim Form*

International Emergency Dental Program Flyer*

International Emergency Dental Program Frequently Asked Questions*

Extra cleaning sign up form for diabetic and pregnant members*

Group Billing Forms

Weekly ASO Billing Schedule

Monthly Fully Insured Billing Schedule

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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.