Employers

Forms and manuals

Manuals

Group Administration Manual (GAM)
The redesigned, easy-to-use GAM keeps you on top of the latest administrative and legislative topics. The manual includes links to applications and forms, a qualifying events chart, billing information, summary of benefits and coverage details and much more.

• Enrollment Eligibility Date Calculator
• New Hire Checklist
• Employee Termination Checklist
• Government Mandates

eBilling User Guide - Special Funded Groups
(PDF, 1.6MB - updated 03/09)

CMS Creditable Coverage Disclosure

Online forms

• Address change form
• Explanation of Benefits (EOB) order form
• ID card order form

Miscellaneous forms

The following forms were created with Adobe Acrobat. Visit the Adobe website to download the latest version of Acrobat Reader. Version 9.0 or higher is required.

• Application for Plan 150 Cancer Only Plan and Hospital Indemnity Plan (HIP) *
  (Form 5-14/105A)
• Application and brochure for Secure 300 / Secure HIP
  (Form 5-26)
• Application for Secure 300 / Secure HIP application *
  (Form 5-26A)
• Authorization for Release of Protected Health Information (HIPAA Form) *
  (Form 29-456)
  • Spanish Version *
• Authorization for the Release of Protected Health Information (PHI) relating to Substance Use Disorder *
  (form 29-456A)
  • Spanish Version *
• Revocation of Authorization for the Release of Protected Health Information (HIPAA Form) *
  (Form 29-457)
  • Spanish Version *
• Automatic Payment Authorization *
  (Form MC806B)
• Banking Change Form (for Self-Funded employers) *
  (Form 84-5)
• Billing Worksheet *
  (Form 5-5)
• Change Form for Group Coverage *
  (Form 29-151)
  • Spanish Version *
• CMS SSN Declination Form (offsite link)
• Continuation Coverage Rights Under COBRA Election Notice Template (offsite link)
• Continuation Coverage Rights Under COBRA General Notice Template (offsite link)
• Coverage of Handicapped Dependent Child Application *
  (Form 15-411)
• Dependent Child Affidavit *
  (Form 29-158)
• Duplicate Coverage Questions *
  (Form 34-705)
• Enrollment Form for Group Coverage *
  (Form 40-127)
  Please also complete life insurance applications if applicable: Life Insurance Forms
  • Spanish Version *
• Health Profile *
  (Form MC547)
  • Spanish Version *
• HIPAA Designation Form *
  (Form MC280)
• Home Delivery Order Form (Mail Order Form) (offsite link)
• USERRA Election Form *
  (Form 29-297)
• Waiver of Enrollment *
  (Form 40-106)
  • Spanish Version *

* You may fill out and print this form using your PDF reader program.

Claim forms

• Blue Cross Blue Shield Global Core Claim Form (offsite link)
• Cancer Plan Claim Form *
  (Form 29-134)
• Claim Appeal Form *
  (Form 34-730WEB)
  • Spanish version *
• Claim Appeal Representative Authorization Form *
  (Form 29-58)
• Hospital Indemnity Plan Claim Form *
  (Form 29-142)
• Member Claim Form *
  Use this form to submit a claim for a prescription drug charge for any BlueRx product, excluding BlueRx Direct.
  (Form 34-4)
  • Spanish version *
• Prescription Drug Claim Form (Prime Therapeutics) *
  Use this form to submit a claim for a prescription drug charge if you have BlueRx Direct.
  (Form 34-148)

* You may fill out and print this form using your PDF reader program.

Further (formerly SelectAccount) forms and guides

• FSA Plan Design Guide *
  (Form X22002)
• HRA Plan Design Guide *
  (Form X22003)
• HRA Enrollment *
  (Form X21988)
• HSA Plan Design Guide *
  (Form XX22001)
• HSA Application *
  (Form X21989)
• HSA Reference Guide
  (Form X22000)

* You may fill out and print this form using your PDF reader program.

Advance Insurance Company of Kansas (AICK)

• Visit the AICK forms page for all Advance Insurance forms