Blue Shield Forms and Applications

This page gives you immediate access to Small Group Health Insurance Forms and Applications for California.

Blue Shield Forms & Applications For Small Groups - California
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Select a Category... Group Medical \| Dental \| Life & Disability \| Vision
Company	Group Medical Forms - EMPLOYEE	Description	Form #	Rev Date	Fillable
Blue Shield	Employee Application	For small groups with 2-50 eligible employees.	C12914	1-2010
Blue Shield	Employee Application - Chinese	Chinese Version	C12914-CH	1-09
Blue Shield	Employee Application - Spanish	Spanish Version	C12914-SP	1-09	Yes
Blue Shield	Employee Application - Vietnamese	Vietnamese Version	C12914-VI	1-09
Blue Shield	Cal-Cobra Election Form		C13141	9-07
Blue Shield	Change Transmittal		C3843	11-05
Blue Shield	Continuing Group Coverage After Federal Cobra/Cal-Cobra Election Form		C18157	6-07
Blue Shield	Domestic Partnership Statement		C-15388	2-05
Blue Shield	Employee Change Transmittal		C3843	5-08
Blue Shield	Full Time Student Certification	To be eligible for coverage, unmarried children aged 19-25 must be enrolled full time in college (minimum of 12 units) or trade school.	C-13125	10-03
Blue Shield	Health Statement	Applicable to all 2-14 enrolling employees and non-guaranteed issue groups only.	C15825	10-09
Blue Shield	Health Statement - Spanish	Spanish Version	C15825-SP	10-09
Blue Shield	Medicare Rx Plan / Medicare Rx Enhanced Plan Enrollment Form		S2468	10-07
Blue Shield	Medicare Supplement Plans Application		C12687	7-08	Yes
Blue Shield	Refusal of Personal Coverage		C19927	8-09	Yes
Blue Shield	Request for Continuity of Care Service for New Account	New Access+HMO Enrollees.	C13095-540	N/A
Blue Shield	Request for Continuity of Care Service for New Account -Spanish	Spanish Version.	C13095-540SP	N/A
Blue Shield	Subscriber Change Request Form		C675-1	6-08
Company	Group Medical Forms - EMPLOYER	Description	Form #	Rev Date	Fillable
Blue Shield	Master Group Application	For 2-50 eligible employees.	C15385	1-2010
Blue Shield	Master Group Application - Chinese	Chinese Version	C15385-CH	4-09
Blue Shield	Master Group Application - Spanish	Spanish Version	C15385-SP	4-09	Yes
Blue Shield	Master Group Application - Vietnamese	Vietnamese Version	C15385-VI	4-09
Blue Shield	Administrators Guide Managing Group Benefits		A11152	9-05
Blue Shield	CalCobra Notification	Employer Notification of Qualifying Event Under Cal-COBRA	C13140	1-09
Blue Shield	Checklist - New Business Submission
Blue Shield	Contract Change Form	For small groups	C15782	1-2010
Blue Shield	Disability Addendum	Disability Addendum	C11248	1-04
Blue Shield	Employer Health Questionnaire	For 15-50 enrolling employees.	C15146	10-09
Blue Shield	Group Name Change Protocol		n/a	2-15-07
Blue Shield	Master Application for Ancillary Products	Small Group Master Application for Ancillary Products	C17607	1-07
Blue Shield	Request for Contract Change	Used to expedite change requests for your client's renewing group contracts.	C15782	1-09	Yes
Blue Shield	Sole Proprietor, Partner, or Corporate Officer Statement	Small Group requirements for proof of eligibility when owners are not listed on DE6.	C15293	1-04
Blue Shield	Verification and Statement of Understanding	Please fill this form out when filling out the Employer Master Group Application C15385 (above).	C20283	7-09
Company	Group Medical Forms - OTHER	Description	Form #	Rev Date	Fillable
Blue Shield	Benefit Summary Guide	Group health plan information for small businesses with 2-50 eligible employees.	A16609	10-07
Blue Shield	Cal-COBRA Take Over	Cal-COBRA Take-Over Form.	C14755	6-07
Blue Shield	Cerdian COBRA Continuation Service Waiver	To be completed by the group benefits administrator.	C15410	5-07
Blue Shield	Claim Form - International - BlueCard Worldwide	Is to be used to submit institutional and professional claims for benefits for covered medical services received outside the United States, Puerto Rico and the U.S. Virgin Islands.	C14764	7-05
Blue Shield	Claim Form - Medical - CDI Filed Plans		CLM-14850	9-03
Blue Shield	Claim Form - Medical - DHMC Filed Plans		CLM-14850	8-02
Blue Shield	Continuity of Care Notice - Established Members		C15712	5-07
Blue Shield	Continuity of Care Notice - New HMO	Continuity of Care Program for newly enrolled Access+ HMO® members to provide a smooth transition of care to a healthcare provider in our network.	A11511	5-07
Blue Shield	Continuity of Care Notice - New Members		C13095	1-07
Blue Shield	Continuity of Care Notice - New HMO - Spanish	Spanish Version	ASP11511	5-07
Blue Shield	Group Request for Contract Change	This form should be used to expedite the change requests for your client's renewing group contacts.	C15782	1-09
Blue Shield	IFP Plan Transfer Matrix		A37988	3-2010
Blue Shield	Pharmacy Reimbursement	Blue Shield of CA Prescription Drug Benefit. Direct Reimbursement Claim.	C14352	4-07
Blue Shield	Probable RAF Form	Small Group Probable Action Request Form	C15408	6-08	Yes
Blue Shield	SM Plan Comparison Guide	Simplifying coverage for small businesses (groups 2-50)	A11368	2-08
Blue Shield	Waiver of Premium Claim Form		ABU1182	5-07
Select a Category... Group Medical \| Dental \| Life & Disability \| Vision
Company	Dental Forms	Description	Form #	Rev Date	Fillable
Blue Shield	Dental Claim Form	Treatment plans exceeding $250.00 should be submitted for precertification. Failure to do so may result in patient responsibility for claims subsequently adjusted or denied.	C11716	8-06
Blue Shield	Dental Only Application	Dental Only Employee Application (No Medical)	C15366	9-06
Blue Shield	Dental Only Application - Spanish	Spanish Version	C15366-SP	9-07
Blue Shield	Instructions For Evidence of Insurability		CP-1021	N/A
Select a Category... Group Medical \| Dental \| Life & Disability \| Vision
Company	Life Insurance Forms	Description	Form #	Rev Date	Fillable
Blue Shield	Subscriber Statement of Claim - Life Form	To be used ONLY when the Provider of Service does not submit your claim directly to Blue Shield.	CLM-15481	9-03
Blue Shield	Proof of Death	Must complete entire claim form to be processed.	ABU1180	10-06
Blue Shield	Dismemberment Claim Form	Dismemberment Claim Form for Blue Shield of California Life & Health Insurance Company (Blue Shield Life).	ABU1181	8-06
Blue Shield	Accelerated Death Benefit Claim Form	Verification will be made upon receipt of the completed form.	ABU1139	8-06
Company	Vision Forms	Description	Form #	Rev Date	Fillable
Blue Shield	N/A

< Go Back OR view forms & apps for: Aetna \| American Fidelity \| Anthem Blue Cross \| Blue Shield \| California Choice \| coPower \| First Horizon \| The Hartford \| Health Net \| HSA Bank HSA California \| Kaiser \| Kaiser Choice Solution \| New Dental Choice \| Premier Access \| Sharp \| Sterling HSA \| The Standard \| UHC / PacifiCare \| Unum Western Health Advantage