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Formularios del Empleador

Nombre y descripción del formulario

Fecha de revisión

Form. de solicitud de cobertura médica/cambios para grupo  – use this form to apply for group coverage or to make a change to an existing BCBSOK policy.

07/2018

Group Enrollment Application/Change Form – Spanish 

07/2018
COBRA Request for Continuation of Coverage  – Application to request continued coverage due to employee's reduction in work hours, retirement, termination, etc. 10/2010 
Formulario de reclamación - Beneficios dentales  - Use este formulario para presentar reclamaciones dentales para reembolsos que no son presentadas por su profesional en servicios dentales.
04/2013
Formulario de reclamación - Beneficios médicos (nacional)  – BCBSOK plan members can 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.
10/2015
Claim Form – Medical (Domestic) – Spanish 
01/2016
Formulario de reclamación - Beneficios médicos (internacional)  – BCBSOK plan members can use this BlueCard Worldwide 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.
01/2017
Claim Form – Medical (International) – Spanish 
01/2017
Formulario de reclamación - Medicamentos con receta  - BCBSOK members with pharmacy benefits can use this form to request reimbursement for a prescription drug purchase. Members must submit the original pharmacy receipt with the completed form to Prime Therapeutics, the BCBSOK pharmacy benefits manager. 01/2016
Claim Form – Prescription Drug (Comprehensive Benefit)  – Only BCBSOK members with the comprehensive prescription drug benefit should use this claim form to request reimbursement from a non-participating pharmacy. 02/2009
Declaración jurada de pareja en unión libre  01/2014
Common Law Marriage Affidavit  09/2019
Medicare Secondary Payer (MSP) Employer Acknowledgement Form 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. 05/2015
Information Regarding Medicare Secondary Payer (MSP) Statute  
06/2009 
MSP Fact Sheet 
06/2012
Formulario de autorización para beneficiario discapacitado (para coberturas individuales)  - 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. El formulario completo se debe enviar por fax o correo a BCBSOK (ver la dirección y el número de fax en la parte superior de este formulario). 07/2019
Formulario de autorización para beneficiario discapacitado (para coberturas grupales)  - 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. El formulario completo se debe enviar por fax o correo a BCBSOK (ver la dirección y el número de fax en la parte superior de este formulario). Este formulario también se puede usar para agregar un beneficiario discapacitado a una nueva póliza (se debe incluir este formulario completo al enviar la solicitud de inscripción). 08/2019
Formulario de licencia médica para alumno dependiente  – 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. 01/2011
Formulario de Autorización Estándar y otros Formularios de Privacidad de la HIPAA - Protected health information (PHI) is defined by privacy rules enacted under the Health Insurance Portability and Accountability Act (HIPAA) of 1996. BCBSOK plan members can use privacy forms to authorize BCBSOK to disclose their PHI. 04/2018

 

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