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Having the information you need at your fingertips is vital when making business decisions. At Blue Cross and Blue Shield of Oklahoma (BCBSOK), we are committed to providing the resources, tools and information you need to help you make the best choices for your employees and your business. And we're committed to helping you stay informed with new postings on legislative updates, new member services and programs, and more. 

Form Name and Description	Revision Date
Group Enrollment Application/Change Form  Use this form to apply for group coverage or to make a change to an existing policy.	09/2024
Group Enrollment Application/Change Form – Spanish	07/2021
2025 Benefit Program Application (BPA) for Small Groups 2-50 2025 Benefit Program Application (BPA) for Small Groups 2-50  For new accounts effective on or after 1/1/2025.	07/2024
2025 Benefit Program Application (BPA) Amendment for Small Groups 2-50 2025 Benefit Program Application (BPA) Amendment for Small Groups 2-50  For renewing Small Group accounts with anniversary dates on or after 1/1/2025; use this form to amend the original BPA.	07/2024
2024 Benefit Program Application (BPA) for Small Groups 2-50 2024 Benefit Program Application (BPA) for Small Groups 2-50  For new accounts effective on or after 1/1/2024.	01/2024
2024 Benefit Program Application (BPA) Amendment for Small Groups 2-50 2024 Benefit Program Application (BPA) Amendment for Small Groups 2-50  For renewing Small Group accounts with anniversary dates on or after 1/1/2024; use this form to amend the original BPA.	01/2024
2025 Important Small Group Benefit Changes/Uniform Modification Notice Identifies some of the most important benefit plan changes for the 2025 coverage year.	01/2025
2024 Important Small Group Benefit Changes/Uniform Modification Notice Identifies some of the most important benefit plan changes for the 2024 coverage year.	01/2024
2025 Benefit Program Application (BPA) for Mid-Market Groups 51-150 2025 Benefit Program Application (BPA) for Mid-Market Groups 51-150  For new accounts effective on or after 1/1/2025.	07/2024
2025 Benefit Program Application (BPA) Amendment for Mid-Market Groups 51-150 2025 Benefit Program Application (BPA) Amendment for Mid-Market Groups 51-150  For renewing Small Group accounts with anniversary dates on or after 1/1/2025; use this form to amend the original BPA.	07/2024
2025 Important Mid-Market Benefit Changes/Uniform Modification Notice Identifies some of the most important benefit plan changes for the 2025 coverage year.	09/2024
2024 Benefit Program Application (BPA) for Mid-Market Groups 51-150 2024 Benefit Program Application (BPA) for Mid-Market Groups 51-150  For new Mid-Market Group accounts effective on or after 1/1/2024.	01/2024
2024 Benefit Program Application (BPA) Amendment for Mid-Market Groups 51-150 2024 Benefit Program Application (BPA) Amendment for Mid-Market Groups 51-150  For renewing Small Group accounts with anniversary dates on or after 1/1/2024; use this form to amend the original BPA.	02/2024
Employer Group Information (EGI) Form This form must be submitted with the BPA	08/2023
COBRA Request for Continuation of Coverage  Application to request continued coverage due to employee's reduction in work hours, retirement, termination, etc.	10/2010
Claim Form – Dental  Use this form to file dental claims for reimbursement that are not filed by your dental provider.	05/2022
Claim Form – Dental – Spanish	05/2022
Claim Form – Medical (Domestic)  Plan members can use this form to request reimbursement for health care services obtained within the U.S., a U.S. territory, when on a cruise ship, or on a U.S. military base.	10/2015
Claim Form – Medical (Domestic) – Spanish	01/2016
Claim Form – Medical (International)  Plan members can use this claim form to request reimbursement for health care services obtained when traveling internationally - when outside of the U.S. or a U.S. territory, but NOT for services obtained on a cruise ship or a U.S. military base.	01/2017
Claim Form – Medical (International) – Spanish	01/2017
Claim Form – Prescription Drug (Prime Therapeutics)  Members with pharmacy benefits through BCBSOK can use this Prime Therapeutics claim form to request reimbursement after they buy a prescription drug or over-the-counter (OTC) COVID-19 home test kit. They must submit the pharmacy counter receipt with the completed form. Cash register receipts for OTC COVID-19 test kits may not be accepted. Not all plans cover OTC COVID-19 home test kits. If your plan does not cover, you will not be reimbursed.	05/2023
Claim Form – Prescription Drug (Prime Therapeutics) – Spanish	03/2022
Affidavit of Domestic Partnership	01/2014
Common Law Marriage Affidavit	09/2019
Medical Loss Ratio (MLR) Written Assurance Form – Complete this standalone form only for an existing group if one of these conditions applies: 1) the group is changing Church designation as defined by the IRS, or 2) it is a Church group wanting to change how the rebate is handled.	04/2023
Medicare Secondary Payer (MSP) Employer Acknowledgement Form (EAF) with Instructions  In the absence of employer-provided employee counts, the Centers for Medicare and Medicaid Services (CMS) requires the employer group health insurance plan be considered primary to Medicare. PDF includes the Annual Medicare Secondary Payer Employer Acknowledgement Form and Instructions for completing the form.	07/2023
Information Regarding Medicare Secondary Payer (MSP) Statute	06/2009
MSP Fact Sheet	06/2012
Disabled Dependent Authorization Form (for Individual Plans)  Members with an Individual 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.	01/2023
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. This form can also be used to add a disabled dependent to a new policy.	10/2022
Dependent Student Medical Leave Form  Public law 110-381 is known as Michelle's Law. Use this form when a dependent college student insured under the parent's policy must take a medical leave of absence.	01/2024
Standard Authorization Form and other HIPAA Privacy Forms  Protected health information (PHI) is defined by privacy rules enacted under the Health Insurance Portability and Accountability Act (HIPAA). BCBSOK plan members can use privacy forms to authorize BCBSOK to disclose their PHI.	07/2022
Average Employee Count (AEC) Form	05/2024

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