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 |
07/2018 |
| 07/2018 | |
2022 Enrollment Package for Small Groups 2-50 |
10/2021 |
| 2023 Benefit Program Application (BPA) for Small Groups 2-50 2023 Benefit Program Application (BPA) for Small Groups 2-50  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 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 |
06/2021 |
2022 Benefit Program Application (BPA) Amendment for Small Groups 2-50 |
06/2021 |
2023 Benefit Program Application (BPA) for Mid-Market Groups 51-150 |
10/2022 |
2023 Benefit Program Application (BPA) Amendment for Mid-Market Groups 51-150 |
10/2022 |
2022 Benefit Program Application (BPA) for Mid-Market Groups 51-150 |
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 |