Empoire Blue Cross Large Group Employee Enrollment Form

New Business/Enrollment Forms

Form Name	Digital Form	Download
Group Enrollment Application/Change Form – Use this form to apply for group coverage effective 1/1/2022, 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 1/1/22 and after	sign now	download form download form
2022 Benefit Plan Selection (BPS) Form – For new accounts effective 1/1/22 and after	sign now	download form download form
2021 Enrollment Package – Includes Benefit Program Application (BPA), Benefit Plan Selection (BPS) Form, MSP Form, and Artifacts Documentation for new accounts effective 1/1/21 and after	sign now	N/A
2021 Benefit Program Application (BPA) – For new accounts effective 1/1/21 and after	sign now	download form download form
2021 Benefit Plan Selection (BPS) Form – For new accounts effective 1/1/21 and after	N/A	download form download form
Employer Group Information (EGI) Form – This form must be submitted with the BPA	sign now	download form
Affidavit of Domestic Partnership	sign now	download form
Affordable Care Act (ACA) Small Group New Business Checklist	N/A	download form
Full-Time Status Certification for Owners, Partners, Proprietors	sign now	download form
General Notice of Special Enrollment Rights	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
Underwriting Reference Guide for Brokers	N/A	download guide

Renewal Forms and Information

Form Name	Digital Form	Download
2022 Benefit Plan Selection (BPS) Form – For new accounts effective 1/1/22 and after	sign now	download form download form
2021 Benefit Plan Selection (BPS) Form – For new accounts effective 1/1/21 and after	N/A	download form download form
2022 Important Benefit Changes/Uniform Modification Notice – Identifies some of the most important benefit plan changes for the upcoming 2022 coverage year	N/A	download letter
Small Group Billing Method Form – For accounts effective 1/1/19 and after	N/A	download form
Small Group Billing Preferences Guide – For accounts effective 1/1/19 and after	N/A	download guide
2019 Small Group Renewal Tips – For accounts effective 1/1/19 and after	N/A	download flier
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 effective 1/1/2022, or to make changes to an existing BCBSIL policy	N/A	download form
Group Enrollment Application/Change Form – Spanish	N/A	download form
Submission Guidelines for Small Group Health Coverage	N/A	download form
General Notice of Special Enrollment Rights	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 effective 1/1/2022, or to make changes to an existing BCBSIL policy	N/A	download form
Group Enrollment Application/Change Form – Spanish	N/A	download form
Submission Guidelines for Small Group Health Coverage	N/A	download form
General Notice of Special Enrollment Rights	N/A	download form

Claim Forms

Form Name	Digital Form	Download
Dental Claim Form – Members should use this form to file dental claims for reimbursement that are not filed by their dental provider.	N/A	download form
Dental Claim Form – Spanish	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 MSP Employer Acknowledgement Form (EAF)  with Instructions	N/A	download form
Individual MSP Form	N/A	download form
Information Regarding MSP Statute	N/A	download form
MSP Fact Sheet	N/A	download form

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) – Members with BCBSIL HMO prescription drug coverage can use AllianceRx Walgreens Prime to order new or refill maintenance prescription drugs for home delivery. Mail the completed form to the address provided on the form, and include the original prescription signed by your doctor.	N/A	download form
Prescription Drug Mail-Order Form (AllianceRx Walgreens Prime) – Spanish	N/A	download form
Prescription Drug Mail-Order Form (Express Scripts) – Members with BCBSIL PPO or HMO prescription drug coverage can use Express Scripts Pharmacy to order new or refill prescription drugs for home delivery. They need to mail the completed form to the address provided on the form, and include the original prescription signed by their doctor.	N/A	download form
Prescription Drug Mail-Order Form (Express Scripts) – Spanish	N/A	download form

Miscellaneous Forms

Form Name	Digital Form	Download
Small Group HCSC/FDL Disclosure Form	N/A	download form
Membership Change Request 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

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Source: https://www.bcbsil.com/employer/forms/downloads/small-group-forms

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