Blue Access for Producers
 

Downloadable Forms for Mid-Market Groups (51-150 Employees)


Here are some commonly used forms for conducting business with Blue Cross and Blue Shield of Oklahoma (BCBSOK). To access more downloadable forms, please log in to Blue Access for Producers.

To review and sign your request now electronically, select the sign now option below. Or you can download and save the form, to review and sign at a later date.


Enrollment Forms and Change Forms

Form Name Digital Form Download
2019 Enrollment Package – includes Benefit Program Application (BPA), MSP Form, and Artifacts Documentation for new accounts effective 1/1/2019 and after sign now External Link N/A
2019 Benefit Program Application (BPA) for Mid-Market Groups 51-150 – for new accounts effective on or after 1/1/2019 sign now External Link download form Word Document
download form Acrobat PDF
2019 Benefit Program Application (BPA) Amendment for Mid-Market Groups 51-150 – for renewing accounts with anniversary dates on or after 1/1/2019; use this form to amend the original BPA N/A download form Word Document
download form Acrobat PDF
Group Enrollment Application/Change Form – use this form to apply for group coverage or to make changes to an existing BCBSOK policy sign now External Link download form Acrobat PDF
Checklist for Obtaining a Quote for New Groups 51-150 N/A download form Acrobat PDF
Checklist for Submitting Sold Non-Regulated Groups 51-150 N/A download form Acrobat PDF
Deductible Credit Form for Employees at Enrollment N/A download form Acrobat PDF
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). N/A download form Acrobat PDF
Request for Continuation Coverage N/A download form Acrobat PDF
NRMM Census Import Table – file must be saved before entering data N/A download form Microsoft Excel Spreadsheet

 

Miscellaneous Forms

Form Name Digital Form Download
Affidavit of Domestic Partnership sign now External Link download form Acrobat PDF
Common Law Marriage Affidavit N/A download form Acrobat PDF
Request to Extend Coverage for Disabled Dependent sign now External Link download form Acrobat PDF

 

Medicare Secondary Payer (MSP) Form and Information

Form Name Digital Form Download
Annual MSP Employer Acknowledgement Form with Instructions on Completing the Form sign now External Link download form Acrobat PDF
Information Regarding the Medicare as Secondary Payer Statute N/A download form Acrobat PDF
MSP Fact Sheet N/A download form Acrobat PDF

 

Legal / HIPAA Forms

Form Name Digital Form Download
Standard Authorization Form and other HIPAA Privacy Forms N/A N/A