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Affidavit of Domestic Partnership
Affidavit of Domestic Partnership Instructions
Change of Status Form (Member)
Use this form to make changes to your coverage. The following changes can be submitted: Name changes, address changes, billing address changes (only for non-group members), PCP (Personal Care Physician) changes, cancellations of self or dependents, and requests for changing billing methods (only for non-group members). Note: For group coverage, you may be required to notify your employer's group leader.
Use this form to apply for COBRA coverage, if available, when group coverage has been terminated.
COBRA Qualifying Event Form
BCBSMT sends this out to you when you have experienced a qualifying event. This is only used when BCBSMT is the administrator of COBRA for a group.
Dental Pediatric Small Group Form
Small Group pediatric dental form for essential health benefits defined by ACA for groups with new policies effective in 2014 and later.
Dental Pediatric Existing Small Group
Small Group pediatric dental form for essential health benefits defined by ACA for existing groups with policies effective prior to 2014.
Electronic Funds Transfer (EFT) Authorization
Only for groups already converted to Blue Access for Members
. Use this form to have premium payments automatically withdrawn from either a checking or savings account.
Employer Group Information (EGI) Form
For Small Employer Groups (2-50) that have reached their 2014 Renewal Dates - Use the EGI form to submit employee counts for COBRA, Medicare Secondary Payor Status and Medical Loss Ratio.
Employer Group Listing
Must accompany employee health statements and Small Group Worksheet to receive a quote outside the BlueKey Portal.
Immunization Claim Form
Use this form to submit preventative immunization service received at a Heath Fair, a City/County Health Dept, Pharmacy, etc. along with a receipt or itemized statement.
Lab Services Claim Form
Use this form to submit laboratory services received at a Heath Fair, a City/County Health Dept, etc. along with a receipt or itemized statement.
Work Hours Endorsement Form
Employers use this form to specify the employer's work hour requirement for eligibility for employees to be eligible for coverage.
Application and/or Waiver of Coverage for Group Benefit Plans
New Small Group App
Renewing Small Group App
Group Application Short Form
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield
Association. © Copyright 2013 Health Care Service Corporation. All Rights Reserved