Downloadable Forms
Get the most from your health insurance coverage by using these helpful forms and documents to make plan changes, add features, file claims and much more.
Note: Forms on this page are available as PDF files. Just click on the appropriate form to view, download and print. You will need the Adobe® Reader® to access these files, which you can download for free at Adobe's site 
. If these downloadable PDF forms are altered in any way they will not be processed by Blue Cross and Blue Shield of Oklahoma.
Customer Service
| Form Name and Description | Revision Date |
|---|---|
Certificate of Creditable Coverage Submission Form  (55kB)This form is used to submit a certificate of creditable coverage (COCC) or CDIB Card. |
Updated 12/2009 |
| BCBSOK Medical Claim Form (member-submitted) (90kB) |
Updated 03/2012 |
| 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. |
Updated 03/2012 |
| Student Certification Form (44kB) This form is required for you to continue health and/or dental coverage for your 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 on 01/2011 |
| COB Questionnaire - Blue Cross and Blue Shield of Oklahoma (34kB) |
Updated 03/2008 |
| COB Questionnaire - BlueLincs (39kB) BlueLincs Coordination of Benefits Questionnaire |
Updated 09/2005 |
Dental Forms
| Form Name and Description | Revision Date |
|---|---|
| Dental Claim Form (145kB) |
Updated 01/2012 |
| Dental Provider Nomination Form (54kB) Use this form to nominate a dental provider (dentist) to be in the network. |
Individual/Family Coverage
| Form Name and Description | Revision Date |
|---|---|
| Product Guides | |
| Product Guide Brochure (1329kB) Or call toll-free 1-866-793-8111 for more information |
Updated 08/2012 |
| Plan Comparison Chart (359kB) |
Updated 06/2011 |
| Health Check and Simply Blue | |
| Health Check and Simply Blue Individual Application and Change in Membership (178kB) |
Updated 06/2011 |
| Health Check and Simply Blue Change Form (82kB) |
Updated 08/2011 |
| Simply Blue Outline of Coverage (194kB) |
Updated 06/2012 |
| Simply Blue Producer Acknowledgement (66kB) |
Updated 06/2011 |
| List Bill Materials (3 forms) (273kB) |
Updated 06/2011 |
| Blue Transitions | |
| Blue Transitions Application (725kB) |
Updated 08/2011 |
| Blue Transitions Debit Authorization Form (50kB) |
Updated 02/2009 |
| Dental (BlueSelect) | |
| BlueSelect Dental application (60kB) |
Updated 12/2010 |
| Request For Underwriting Opinion | |
| Request For Underwriting Opinion Form (37kB) |
|
Medicare Supplement
| Form Name and Description | Revision Date |
|---|---|
| Product Guide | |
| Plan65 and Blue Plan65 Select Brochure (990kB) |
Updated 03/2011 |
| Application Forms | |
| Updated 03/2010 | |
|
Information Regarding The Medicare as Secondary Payer Statute |
Updated 02/2007 |
|
Updated 02/2007 |
|
| Outline of Coverage | |
| Plan65 and Blue Plan65 Select Outline of Coverage (649kB) |
Updated 01/2011 |
| Sales Materials | |
| Plan65 and Blue Plan65 Select Benefit Chart and Rates (90kB) |
Updated 01/2011 |
Prescription Drug Forms
| Form Name and Description | Revision Date |
|---|---|
| PrimeMail New Prescription Order Form (236kB) Members with BCBSOK prescription drug coverage can use this form to mail order new prescription maintenance medication. Mail the completed form to PrimeMail, and include the original prescription signed by your doctor. |
Updated 12/2010 |
| PrimeMail Refill Prescription Order Form (362kB) Members with BCBSOK prescription drug coverage can use this form to mail order refills for prescribed maintenance medication. |
Updated 12/2010 |
| 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. You must submit the original pharmacy receipt with the completed form to Prime Therapeutics, the BCBSOK pharmacy benefits manager. |
Updated 01/2012 |
| Prescription Drug Claim Form (for Individual Plan members) (216kB) BCBSOK members with pharmacy benefits through an individual insurance plan can use this form to request reimbursement for a prescription drug purchase. You must submit the original pharmacy receipt with the completed form to Prime Therapeutics, the BCBSOK pharmacy benefits manager. |
Updated 01/2013 |
