Employer Forms
| Form Name and Description | Revision Date |
|---|---|
|
Enrollment Application/Change Form — English |
Updated 09/2011 |
|
Small Business Enrollment Application/Change Form — English Spanish (143kB) |
Updated 10/2011 |
| Standard Authorization Form and other HIPAA Privacy Forms Authorizes Blue Cross and Blue Shield of Oklahoma to disclose protected health information only to those individuals specified by the member. Protected health information is defined by privacy rules enacted under the Health Insurance Portability and Accountability Act (HIPAA) of 1996. |
|
| BCBSOK COBRA Continuation Coverage (58kB) |
|
| BlueSelect Dental Application (140kB) |
|
| BCBSOK Medical Claim Form (member-submitted) (90kB) |
Updated 03/2012 |
| Certificate of Coverage (80kB) |
|
| Common Law Marriage Affidavit (31kB) |
|
| Dental Claim Form (145kB) |
Updated 01/2012 |
| Medicare Secondary Payer (MSP) Employer Acknowledgement Form with Instructions (155kB) |
Updated 01/2011 |
| Information Regarding Medicare Secondary Payer (MSP) Statute (301kB) |
Updated 01/2011 |
| MSP Fact Sheet (388kB) |
Updated 06/2012 |
| Plan65 Blue Plan65 Select Application (223kB) |
|
| Student Certification Form (44kB) This form is required for members to continue health and/or dental coverage for their dependent child age 19 or older, as long as he or she is an unmarried, full-time student. |
Updated 06/2011 |
| Dependent Student Medical Leave Form (33kB) |
Added 01/2011 |
| Comprehensive Prescription Drug Claim Form (37kB) |
Updated 02/2009 |
| Prescription Drug Claim Form (for Group Plan members) (264kB) BCBSOK members with pharmacy benefits through an employer group insurance plan 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. |
Updated 01/2012 |
