Formularios del Empleador

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.

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 policy.

07/2018

Group Enrollment Application/Change Form – Spanish

07/2018

2022 Enrollment Package for Small Groups 2-50 
Includes Small Group Benefit Program Application (BPA), EGI Form, and Artifacts Documentation for new accounts effective 1/1/22 and after

10/2021
2023 Benefit Program Application (BPA) for Small Groups 2-50
2023 Benefit Program Application (BPA) for Small Groups 2-50 Documento de Word
For new Small Group accounts effective on or after 1/1/2023.
06/2022
2023 Benefit Program Application (BPA) Amendment for Small Groups 2-50
2023 Benefit Program Application (BPA) Amendment for Small Groups 2-50 Documento de Word
For renewing Small Group accounts with anniversary dates on or after 1/1/2023; use this form to amend the original BPA.
06/2022
Employer Group Information (EGI) Form for Small Groups
This form must be submitted with the BPA
11/2022
Employer Group Information (EGI) Form for Mid Market Groups
This form must be submitted with the BPA
11/2022

2022 Benefit Program Application (BPA) for Small Groups 2-50
2022 Benefit Program Application (BPA) for Small Groups 2-50 Documento de Word
For new Small Group accounts effective on or after 1/1/2022.

06/2021

2022 Benefit Program Application (BPA) Amendment for Small Groups 2-50
2022 Benefit Program Application (BPA) Amendment for Small Groups 2-50 Documento de Word
For renewing Small Group accounts with anniversary dates on or after 1/1/2022; use this form to amend the original BPA.

06/2021

2023 Benefit Program Application (BPA) for Mid-Market Groups 51-150
2023 Benefit Program Application (BPA) for Mid-Market Groups 51-150 Documento de Word
For new Mid-Market Group accounts effective on or after 1/1/2023.

10/2022

2023 Benefit Program Application (BPA) Amendment for Mid-Market Groups 51-150
2023 Benefit Program Application (BPA) Amendment for Mid-Market Groups 51-150 Documento de Word
For renewing Small Group accounts with anniversary dates on or after 1/1/2023; use this form to amend the original BPA.

10/2022

2022 Benefit Program Application (BPA) for Mid-Market Groups 51-150
2022 Benefit Program Application (BPA) for Mid-Market Groups 51-150 Documento de Word
For new Mid-Market Group accounts effective on or after 1/1/2022.

06/2021
2023-2024 Important Small Group Benefit Changes/Uniform Modification Notice
Identifies some of the most important benefit plan changes for the upcoming 2023-2024 coverage year.
03/2023
COBRA Request for Continuation of Coverage 
Application to request continued coverage due to employee's reduction in work hours, retirement, termination, etc.
10/2010 
Formulario de reclamación - Beneficios dentales 
Use este formulario para presentar reclamaciones dentales para reembolsos que no son presentadas por su profesional en servicios dentales.
05/2022
Claim Form – Dental – Spanish
05/2022
Formulario de reclamación - Beneficios médicos (nacional) 
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
Formulario de reclamación - Beneficios médicos (internacional) 
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) 
Los asegurados que tienen beneficios farmacéuticos a través de BCBSTX pueden usar este formulario de reclamación de Prime Therapeutics para solicitar el reembolso por la compra de un medicamento con receta o un kit de prueba de diagnóstico de COVID-19 de venta libre para uso domiciliario. Para medicamentos con receta, usted debe presentar el recibo original de la farmacia con el formulario completo. Para kits de prueba de diagnóstico de COVID-19 para uso domiciliario, usted debe presentar el recibo de caja original o el recibo electrónico con el formulario completo.
03/2022
Claim Form – Prescription Drug (Prime Therapeutics) – Spanish 03/2022
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 (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.
04/2021
Information Regarding Medicare Secondary Payer (MSP) Statute  
06/2009 
Hoja informativa sobre el MSP 
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. 
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. This form can also be used to add a disabled dependent to a new policy.
10/2022
Formulario de licencia médica para alumno dependiente 
La ley pública 110-381 se conoce como "Ley de Michelle". Use este formulario cuando un estudiante universitario beneficiario de la póliza de seguro de los padres tenga que pedir una licencia médica.
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). BCBSOK plan members can use privacy forms to authorize BCBSOK to disclose their PHI.
07/2022