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Employer Forms:

All Forms

  • 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.  
  • COBRA Election
    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 Employers. Use this form to have premium payments automatically withdrawn from either a checking or savings account.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.

Applications


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