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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
Formulario de solicitud de coberturas grupales/cambios - Español	07/2018
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
2024 Important Small Group Benefit Changes/Uniform Modification Notice Identifies some of the most important benefit plan changes for the 2024 coverage year.	09/2023
2023 Benefit Program Application (BPA) for Small Groups 2-50 2023 Benefit Program Application (BPA) for Small Groups 2-50  For new 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
2023 Benefit Program Application (BPA) for Mid-Market Groups 51-150 2023 Benefit Program Application (BPA) for Mid-Market Groups 51-150  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  For renewing Small Group accounts with anniversary dates on or after 1/1/2023; use this form to amend the original BPA.	10/2022
Employer Group Information (EGI) Form This form must be submitted with the BPA	08/2023
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)  Members with pharmacy benefits through BCBSOK can use this Prime Therapeutics claim form to request reimbursement after they buy a prescription drug or over-the-counter (OTC) COVID-19 home test kit. Deberán enviar el recibo de caja de la farmacia junto con el formulario completo. Es posible que no se acepten los recibos de caja para kits de prueba de COVID-19 de venta libre. No todas las coberturas incluyen los kits de prueba de COVID-19 de venta libre para uso domiciliario. Si su cobertura no los incluye, no recibirá el reembolso.	05/2023
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
Medical Loss Ratio (MLR) Written Assurance Form – Complete this standalone form only for an existing group if one of these conditions applies: 1) the group is changing Church designation as defined by the IRS, or 2) it is a Church group wanting to change how the rebate is handled.	04/2023
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.	07/2023
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.	01/2023
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

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