Download your Blue Cross and Blue Shield of Oklahoma (BCBSOK) group business forms here, via our FormFinder tool or in the listing below.
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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 |
07/2018 |
Formulario de solicitud de coberturas grupales/cambios - Español |
07/2018 |
| 2024 Benefit Program Application (BPA) for Small Groups 2-50 2024 Benefit Program Application (BPA) for Small Groups 2-50  For new accounts effective on or after 1/1/2024. |
06/2023 |
| 2024 Benefit Program Application (BPA) Amendment for Small Groups 2-50 2024 Benefit Program Application (BPA) Amendment for Small Groups 2-50 For renewing Small Group accounts with anniversary dates on or after 1/1/2024; use this form to amend the original BPA. |
06/2023 |
| 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 Identifica algunos de los cambios más importantes en la cobertura de beneficios para el año de cobertura 2024. |
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 |
Solicitud del programa de beneficios (BPA, en inglés) para grupos de mercados medianos 51-150 2024 |
06/2023 |
Enmienda de la solicitud del programa de beneficios (BPA, en inglés) para grupos de mercados medianos 51-150 2024 |
06/2023 |
Solicitud del programa de beneficios (BPA, en inglés) para grupos de mercados medianos 51-150 2023 |
10/2022 |
Enmienda de la solicitud del programa de beneficios (BPA, en inglés) para grupos de mercados medianos 51-150 2023 |
10/2022 |
| Formulario de información del grupo de empleadores (EGI, en inglés) Este formulario debe presentarse con la 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 |
| Formulario de reclamación de medicamentos recetados (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 |
| Formulario de garantía por escrito de la tasa de pérdidas médicas (MLR) - Complete este formulario aparte exclusivamente para un grupo existente si se da una de estas condiciones: 1) el grupo cambia su denominación de Iglesia según la definición del IRS, o 2) se trata de un grupo de una Iglesia que desea cambiar la forma en que se gestiona el reembolso. | 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. |
01/2024 |
| 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 |