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360° Health®

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

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  
Dental Prime and Dental Complete Broker Services
Dental Prime and Dental Complete Employer Services
Enrollment Eligibility Checklist
Employee Enrollment Form - Small/Large Group, 2-50 employees - Fillable
Employee Enrollment Form - Small/Large Group, 2-50 employees - Printable
Non-ACA Employee Enrollment Form 2-99 - Fillable
Non-ACA Employee Enrollment Form 2-99 - Printable
 
Member Change  
Cancellation Form - Small Group
Member Enrollment Change Form - Printable
Member Enrollment Change Form - Fillable
Employee Change Application: 2-50 Employee Small Groups - Printable
Employee Change Application: 2-50 Employee Small Groups - Fillable
Employee Change Application: 2-50 Employee Small Groups – Spanish – Fillable
 
Group Application  
Group Commission Agreement – Single Case
Group Enrollment Checklist
Greater Georgia Life Enrollment Form
Employer Enrollment - Small Group, 2-50 employees - Fillable
Employer Enrollment - Small Group, 2-50 employees - Printable
ACA Demographic and Benefit Plan Change Form
Non-ACA Employer Enrollment Application Printable
 

Large Group (51 or more Employees)

Member Applications  
Dental Prime and Dental Complete Broker Services
Dental Prime and Dental Complete Employer Services
Employee Application - Printed version
Employee Application - Fillable version
 
Member Change  
Cancellation Authorization Form – Large Group
Member Enrollment Change Form - Fillable Version
 
Group Application  
Group Enrollment Checklist (51-99)
Group Enrollment Checklist (100+)
Georgia Enrollment and Billing Macro Spreadsheet
Employer Application – Printed Version
Employer Application – Fillable Version
Member Enrollment Application Tips (51-99)
Member Enrollment Application Tips (100+)
Macro Master Copy Enrollment Tool
 

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.
 

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
 

HIPAA

Conditioned Authorization Form
Conditioned Authorization Form - Instructions
 

Miscellaneous

EFT Authorization Form
Certificate of Dependency Form
Dependent Care Spending Account Claim Form
Agent Direct Deposit Form
Eligibility Status Verification Form
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)
Internet Eligibility Agreement
Life & Disability Forms
Third Party Agreement
Username Policy and Usage Agreement
Broker Contact Sheet
Employer Contact Sheet
 
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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.