Form Name and Description
2019 Group Enrollment Application/Change Form – use this form to apply for group coverage effective 1/1/2019, or to make a change to an existing BCBSOK policy.
|COBRA Request for Continuation of Coverage – Application to request continued coverage due to employee's reduction in work hours, retirement, termination, etc.||10/2010|
|Claim Form – Dental – Use this form to file dental claims for reimbursement that are not filed by your dental provider.
|Claim Form – Medical (Domestic) – BCBSOK plan members can 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.
|Claim Form – Medical (Domestic) – Spanish
|Claim Form – Medical (International) – BCBSOK plan members can use this BlueCard Worldwide 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.
|Claim Form – Medical (International) – Spanish
|Claim Form – Prescription Drug – BCBSOK members with pharmacy benefits can use this form to request reimbursement for a prescription drug purchase. Members must submit the original pharmacy receipt with the completed form to Prime Therapeutics, the BCBSOK pharmacy benefits manager.||01/2016|
|Claim Form – Prescription Drug (Comprehensive Benefit) – Only BCBSOK members with the comprehensive prescription drug benefit should use this claim form to request reimbursement from a non-participating pharmacy.||02/2009|
|Affidavit of Domestic Partnership||01/2014|
|Common Law Marriage Affidavit||09/2019|
|Medicare Secondary Payer (MSP) Employer Acknowledgement Form with Instructions – In the absence of employer-provided employee counts, the Centers for Medicare and Medicaid Services (CMS) requires the employer group health insurance plan be considered primary to Medicare. PDF includes the Annual Medicare Secondary Payer Employer Acknowledgement Form and Instructions for completing the form.||05/2015|
|Information Regarding Medicare Secondary Payer (MSP) Statute
|MSP Fact Sheet
|Disabled Dependent Authorization Form (for Individual Plans) – Members with an Individual health plan should use this form to request continuation of coverage on their existing policy for a dependent who is incapable of self-support because of mental or physical impairment. Mail or fax the completed form to BCBSOK (see address and fax number at the top of the form).||07/2019|
|Disabled Dependent Authorization Form (for Group Plans) – Members with an employer-sponsored health plan should use this form to request continuation of coverage on their existing policy for a dependent who is incapable of self-support because of mental or physical impairment. Mail or fax the completed form to BCBSOK (see address and fax number at the top of the form). You can also use this form to add a disabled dependent to a new policy (include this completed form when you submit your enrollment application).||08/2019|
|Dependent Student Medical Leave Form – Public law 110-381 is known as Michelle's Law. Use this form when a dependent college student insured under the parent's policy must take a medical leave of absence.||01/2011|
|Standard Authorization Form and other HIPAA Privacy Forms – Protected health information (PHI) is defined by privacy rules enacted under the Health Insurance Portability and Accountability Act (HIPAA) of 1996. BCBSOK plan members can use privacy forms to authorize BCBSOK to disclose their PHI.||04/2018|