• INDIVIDUAL PRODUCTS
• MEDICARE PLANS
• GROUP
• LIFE & DISABILITY
• AUTHORIZATION FORMS
• FEDERAL EMPLOYEE (FEP) AUTHORIZATION FORMS
• CLAIMS FORM
• COBRA AND SPECIAL ENROLLMENT FORMS
• MISCELLANEOUS MEMBER FORMS
• YOUR SPECIAL ENROLLMENT PERIOD RIGHTS
• NOTICE OF PREEXISTING CONDITION EXCLUSION
• PRESCRIPTION ORDER FORMS

INDIVIDUAL PRODUCTS

• Individual & Family BlueChoices/Regence HSA Healthplan Application
• Plan Change Form
• Conversion Application
• Individual and Family Plan Outline of Coverage
• Individual Plans Comparison
• Individual Health Questionnaire
• SurePay Information and Authorization
• Authorization for My Protected Health Information
• Individual Health Change Form E-27
• Application for Crediting Prior Coverage
• Individual Health Questionnaires Scroll down and choose a form -------------------------------------------- ACNE / SKIN DISORDERS ALCOHOL / DRUG ADDICTION ARTHRITIS / BONE / MUSCLE BACK OR NECK CHEST PAIN COLITIS / IRRITABLE BOWEL SYNDROME CYST / POLYP / TUMOR / BREAST DIVERTICULITIS / DIVERTICULOSIS EYE OR EAR FEMALE DISORDERS GOUT HEADACHE OR MIGRAINE HEART MURMUR / MITRAL VALVE PROLAPSE / RHEUMATIC FEVER HERNIA / GERD KIDNEY / BLADDER / PROSTATE MENTAL / NERVOUS DISORDERS RESPIRATORY DISORDERS / ASTHMA / BRONCHITIS / SINUSES / ALLERGIES SHOULDER / KNEE / JOINT SEIZURE / EPILEPSY THYROID ULCER

MEDICARE PLANS

• Application for Supplement
• BlueSelect Program Book
• BlueSelect Rates
• Medicare Supplement Program Book
• Medicare Supplement Rates
• SurePay Form for Medicare
  • 2008 (PDF)
  • 2009 (PDF)
• Enrollment Forms for:
  • Regence MedAdvantage
    • 2008 (PDF)
    • 2009 (PDF)
  • Regence Life and Health Medicare Script
    • 2008 (PDF)
    • 2009 (PDF)
• Short Enrollment Forms (for existing members to upgrade their plan)
  • Regence MedAdvantage
    • 2008 (PDF)
    • 2009 (PDF) - Coming soon
  • Regence Life and Health Medicare Script
    • 2008 (PDF)
    • 2009 (PDF) - Coming soon

GROUP
Complete the following forms:

New Small Groups (2-50)
New Mid-Size Groups (51-99)
New Large Groups (100+)

New Small Groups (2-50)

• Prior Coverage Information
• Application for Enrollment/Waiver (Print and complete two copies of this PDF form. Sign one form and send it in, save the second for your records.)
• Application for Enrollment/Waiver SPANISH
• Group Application Form (Print and complete two copies of this PDF form. Sign one form and send it in, save the second for your records.)
• Group Change Form
• Group Health Questionnaire (Print and complete two copies of this PDF form. Sign one form and send it in, save the second for your records.)
• Group Health Questionnaire SPANISH
• Letter in lieu of “Quarterly Wage & Tax Report” (For New Businesses Only)
• New Group Proposal Request - Legacy Products
• Small Group Employee Waiver Form (to be completed when employee and all dependents are waiving coverage)
• Small Group (2-50) Checklist (for agent use)
• Stand Alone Dental Underwriting Assumptions and Requirements
• Group Dental Application
• Underwriting Assumptions and Requirements for Groups Size 2-50

New Medium Groups (51-99)

• Prior Coverage Information
• Application for Enrollment/Waiver (Print and complete two copies of this PDF form. Sign one form and send it in, save the second for your records.)
• Application for Enrollment/Waiver SPANISH
• Group Application Form (Print and complete two copies of this PDF form. Sign one form and send it in, save the second for your records.)
• Group Change Form
• Mid-Size Group Proposal Request Checklist
• New Group Proposal Request - Legacy Products
• Risk Evaluation Form
• Short Form Health Questionnaire & Medical history (Contact Marketing rep for use)
• Short Form Health Questionnaire & Medical history SPANISH
• Group Dental Application
• Stand Alone Dental Underwriting Assumptions and Requirements

New Large Groups (100+)

• Application for Enrollment/Waiver (Print and complete two copies of this PDF form. Sign one form and send it in, save the second for your records.)
• Application for Enrollment/Waiver SPANISH
• Prior Coverage Information
• Group Application Form (Print and complete two copies of this PDF form. Sign one form and send it in, save the second for your records.)
• Dental Application for Regence BlueCross BlueShield Dental of Regence ValueCare Dental
• Group Change Form
• Large Group Proposal Request
• Verification of Fee Arrangement (for agent)

AUTHORIZATION FORMS

• Agent Automatic Deposit Authorization Form
• Authorization for Use and Disclosure of Protected Health Information
• Authorization for Use and Disclosure of Protected Health Information - Spanish

FEDERAL EMPLOYEE (FEP) AUTHORIZATION FORMS

• Authorization for Use and Disclosure of Protected Health Information

CLAIM FORM

• Member Reimbursement Claim Form

COBRA AND SPECIAL ENROLLMENT FORMS

• COBRA Booklet
• COBRA, USERRA or STATE CONTINUATION Application
• Health Questionnaire (must accompany SEP form)
• Special Enrollment Period (SEP) Form
• Special Enrollment Period (SEP) Form SPANISH

MISCELLANEOUS MEMBER FORMS

• Change Form "E-27" (Complete this PDF form and print two copies. Sign one form and send it in, save the second for your records.)
• Change Form "E-27" SPANISH
• Dependent Child Certification
• Affidavit of Qualifying Incapacitated Dependent Eligibility (Fillable PDF)
• Conversion Application
• Incident Report
• Individual Health Questionnaire (form to accompany E-27 when adding a dependent)
• Other Insurance Information

PRESCRIPTION ORDER FORMS

• Postal Prescription Services (PPS) Registration & Prescription Order Form
• Walgreens Mail Service Registration & Prescription Mail Order Form
• Walgreens Prescription Fax Order Form

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