Employer Forms
Form Name and Description |
Revision Date |
---|---|
Group Enrollment Application/Change Form |
07/2018 |
07/2018 | |
COBRA Request for Continuation of Coverage ![]() |
10/2010 |
Claim Form – Dental ![]() |
04/2013 |
Claim Form – Medical (Domestic) ![]() |
10/2015 |
Claim Form – Medical (Domestic) – Spanish ![]() |
01/2016 |
Claim Form – Medical (International) ![]() |
01/2017 |
Claim Form – Medical (International) – Spanish ![]() |
01/2017 |
Claim Form – Prescription Drug ![]() |
01/2016 |
Claim Form – Prescription Drug (Comprehensive Benefit) ![]() |
02/2009 |
Affidavit of Domestic Partnership ![]() |
01/2014 |
Common Law Marriage Affidavit ![]() |
09/2019 |
Medicare Secondary Payer (MSP) Employer Acknowledgement Form with Instructions ![]() |
05/2015 |
Information Regarding Medicare Secondary Payer (MSP) Statute ![]() |
06/2009 |
MSP Fact Sheet ![]() |
06/2012 |
Disabled Dependent Authorization Form (for Individual Plans) ![]() |
07/2019 |
Disabled Dependent Authorization Form (for Group Plans) ![]() |
08/2019 |
Dependent Student Medical Leave Form ![]() |
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 |