Medicare Plans
Individual & Family Plans
Sales Toolkits
Here are some commonly used forms for conducting business with Blue Cross and Blue Shield of Oklahoma (BCBSOK). To access more downloadable forms, please log in to Blue Access for Producers.
The forms below are in portable document format (PDF). To view these files, you may need to install a PDF reader program. Most PDF readers are a free download. One option is Adobe® Reader®.
Current Individual Forms |
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| Stock # / Date | Enrollment Forms and Change Forms | Oklahoma Form # |
| 606465.1024 | 2025 Individual Paper Application Checklist | N/A |
| 606681.1124 | 2025 Individual Paper Application Checklist (Spanish Version) | N/A |
| 73447.1024 | 2025 Health Application/Change in Coverage – Use this health application for 2025 plans effective January 1, 2025. | N/A |
| 600313.1124 | 2025 Health Application/Change in Coverage (Spanish Version) | N/A |
| 600001.1024 | 2025 Dental Application/Change in Coverage – Use this dental application for 2025 plans effective January 1, 2025. | N/A |
| 600314.1124 | 2025 Dental Application/Change in Coverage (Spanish Version) | N/A |
| 601673.1024 | 2025 Individual Paper Application Overflow Page | N/A |
| 601685.1124 | 2025 Individual Paper Application Overflow Page (Spanish Version) | N/A |
| 606465.1023 | 2024 Individual Paper Application Checklist | N/A |
| 606681.1123 | 2024 Individual Paper Application Checklist (Spanish Version) | N/A |
| 73447.0124 | 2024 Health Application/Change in Coverage – Use this health application for 2024 plans effective January 1, 2024. | N/A |
| 600313.0124 | 2024 Health Application/Change in Coverage (Spanish Version) | N/A |
| 600001.0124 | 2024 Dental Application/Change in Coverage – Use this dental application for 2024 plans effective January 1, 2024. | N/A |
| 600314.0124 | 2024 Dental Application/Change in Coverage (Spanish Version) | N/A |
| 601673.1023 | 2024 Individual Paper Application Overflow Page | N/A |
| 601685.1123 | 2024 Individual Paper Application Overflow Page (Spanish Version) | N/A |
| Stock # / Date | Account Maintenance Forms |
Oklahoma Form # |
| 72008.0222 | Auto Bill Pay - Automatic Premium Payment Authorization Agreement | N/A |
| 600901.1018 | Auto Bill Pay - Automatic Premium Payment Authorization Agreement - Spanish | N/A |
| 614380.0123 | 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. Mail or fax the completed form to BCBSOK (see address and fax number at the top of the form). | N/A |
| Stock # / Date | Legal / HIPAA Forms |
Oklahoma Form # |
| 07.01.22 | Standard Authorization Form and other HIPAA Privacy Forms | N/A |
Last Updated: Oct. 31, 2024
