|Form Name and Description||Revision Date|
Small Business Enrollment Application/Change Form— English Spanish (143kB)
|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)
|Certificate of Coverage (80kB)
|Common Law Marriage Affidavit (31kB)
|Dental Claim Form (145kB)
|Medicare Secondary Payer (MSP) Employer Acknowledgement Form with Instructions (155kB)
|Information Regarding Medicare Secondary Payer (MSP) Statute (301kB)
|MSP Fact Sheet (388kB)
|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.
|Dependent Student Medical Leave Form (33kB)
|Comprehensive Prescription Drug Claim Form (37kB)
|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.