Downloadable Forms for Mid-Market Groups (51-150 Employees)

Here are some commonly used forms for conducting business with Blue Cross and Blue Shield of Illinois (BCBSIL). Non-regulated cases with 51 or more total employees on average over the prior calendar year including all eligible and ineligible employee types such as temporary, union, seasonal, and part-time employees. This includes employees of controlled/affiliated entities and domestic parent companies.

To access more downloadable forms, please log in to Blue Access for Producers. To review and sign your request now electronically, select the sign now option below. Or you can download and save the form, to review and sign at a later date.

New Business/Enrollment Forms

Form Name	Digital Form	Download
Group Enrollment Application/Change Form – Use this form to apply for group coverage or to make changes to an existing BCBSIL policy	N/A	download form
Group Enrollment Application/Change Form – Spanish	N/A	download form
2022 Enrollment Package – Includes Benefit Program Application (BPA), Benefit Plan Selection (BPS) Form, EGI Form and Artifacts Documentation for new accounts effective 1/1/22 and after	sign now	N/A
2022 Benefit Program Application (BPA) – For new accounts effective 1/1/2022 and after	sign now	N/A
2021 Enrollment Package – Includes Benefit Program Application (BPA), Benefit Plan Selection (BPS) Form, EGI Form and Artifacts Documentation for new accounts effective 7/1/2021 and after	sign now	N/A
2021 Benefit Program Application (BPA) – For new accounts effective 1/1/2021 and after	sign now	download form download form
2021 Benefit Plan Selection (BPS) Form – For new accounts effective 7/1/2021 and after	sign now	download form download form
Employer Group Information (EGI) Form – This form must be submitted with the BPA	sign now	download form
Illinois Extension Form	sign now	download form
HMO/CPO Provider Selection Enrollment and Change Form	N/A	download form
Mid-Market New Business Checklist – for State Area Brokers	N/A	download form
Mid-Market New Business Checklist – for Chicago Metro Brokers	N/A	download form
Smart Census Import Tool (To obtain the latest version of the tool, please log into Blue Access for Producers.)	N/A	N/A
Full-Time Status Certification for Owners, Partners, Proprietors	sign now	download form
Affidavit of Domestic Partnership	sign now	download form
BlueTrack Process Flier	N/A	download flier
Mid-Market Initial Premium EFT Payment Form	sign now	download form

Renewal Forms and Information

Form Name	Digital Form	Download
Group Enrollment Application/Change Form – Use this form to make changes to an existing BCBSIL policy	N/A	download form
Group Enrollment Application/Change Form – Spanish	N/A	download form
Addendum to the Insured BPA Regarding Affiliated Companies	sign now	download form

BlueCare PPO Dental Forms

Form Name	Digital Form	Download
Group Enrollment Application/Change Form – Use this form to apply for group coverage or to make changes to an existing BCBSIL policy	N/A	download form
Group Enrollment Application/Change Form – Spanish	N/A	download form

BlueCare HMO Dental Forms

Form Name	Digital Form	Download
Group Enrollment Application/Change Form – Use this form to apply for group coverage or to make changes to an existing BCBSIL policy	N/A	download form
Group Enrollment Application/Change Form – Spanish	N/A	download form
HMO/CPO Provider Selection Enrollment and Change Form	N/A	download form

Claim Forms

Form Name	Digital Form	Download
Dental Claim Form	N/A	download form
Medical Claim Form (Domestic) – Members should use this form to request reimbursement for health care services obtained within the United States, a U.S. territory, when on a cruise ship, or on a U.S. military base.	N/A	download form
Medical Claim Form (Domestic) – Spanish	N/A	download form
Medical Claim Form (International) – Members should use this claim form to request reimbursement for health care services obtained when traveling internationally – when outside of the United States or a U.S. territory, but NOT for services obtained on a cruise ship or a U.S. military base.	N/A	download form
Medical Claim Form (International) – Spanish	N/A	download form
Prescription Drug Claim Form (Prime Therapeutics) – Members with pharmacy benefits through BCBSIL can use this Prime Therapeutics claim form to request reimbursement for a prescription drug purchase. They must submit the original pharmacy receipt with the completed form.	N/A	download form
Prescription Drug Claim Form (Prime Therapeutics) – Spanish	N/A	download form

Medicare Secondary Payer (MSP) Forms and Information

Form Name	Digital Form	Download
Annual Medicare Secondary Payer (MSP) Employer Acknowledgement Form with Instructions	sign now	download form
Information Regarding Medicare as Secondary Payer Statute	N/A	download flier
MSP Fact Sheet	N/A	download flier

Prescription Drug Forms

Form Name	Digital Form	Download
Prescription Drug Claim Form (Prime Therapeutics) – Members with pharmacy benefits through BCBSIL can use this Prime Therapeutics claim form to request reimbursement for a prescription drug purchase. They must submit the original pharmacy receipt with the completed form.	N/A	download form
Prescription Drug Claim Form (Prime Therapeutics) – Spanish	N/A	download form
Prescription Drug Mail-Order Form (AllianceRx Walgreens Prime) – for HMO Group Plans and Individual Plans	N/A	download form
Prescription Drug Mail-Order Form (AllianceRx Walgreens Prime) – Spanish	N/A	download form
Prescription Drug Mail-Order Form (Express Scripts) – for PPO and HMO Group Plans and Individual Plans	N/A	download form
Prescription Drug Mail-Order Form (Express Scripts) – Spanish	N/A	download form
Women's Contraceptive Coverage List	N/A	download list

Miscellaneous

Form Name	Digital Form	Download
Small Group HCSC/FDL Disclosure Form	N/A	download form
IL Employee Continuation Privilege Election Form	N/A	download form
IL Continuation Group Request Form	N/A	download form
Statement of Termination of Domestic Partnership	N/A	download form
Tax Information on Health Benefits for Domestic Partnership	N/A	download form
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. Mail or fax the completed form to BCBSIL (see address and fax number at the top of the form). You can also use this form to add a disabled dependent to a new policy (include this completed form when you submit your enrollment application).	N/A	download form
Producer of Record Transfer Form and Instructions	N/A	download form

Legal / HIPAA Forms

Form Name	Digital Form	Download
Standard Authorization Form and other HIPAA Privacy Forms	N/A	N/A