| Forms |
Descriptions |
| ENROLLMENT & CHANGE
FORMS |
| Application
for Crediting Prior Coverage (PDF) |
Use this form to provide information about any
health insurance coverage you and/or your dependents
have had during the past 24 months. |
Application for Enrollment/
Waiver E-5 (PDF)
• English
(fillable PDF)
• Spanish
Group Health Questionnaire (PDF)
• English
• Spanish
Short
Form Health Questionnaire and Medical History
Statement (PDF)
• English
• Spanish
Small
Group Employee Waiver Form (PDF) |
Use this form to add a new employee.
This form is also used for employees who decline
health-care coverage through Regence BlueCross
BlueShield of Utah. (Complete this PDF form online
and print two copies. Sign one form and send it
in, save the second for your records.)
Group Health Questionnaire must accompany the
Application for Enrollment/Waiver E-5 for newly
eligible employees whose employer is a group
sized 2-50. (Keep a copy of this form for your records.)
This form must accompany the Application for Enrollment/Waiver
(E5) for newly enrolling employees in groups size
51-99.
Complete when waiving coverage for self and all
dependents. |
| Conversion
Application (PDF) |
For individuals who have exhausted COBRA or Utah State Continuation benefits. |
| Dental
Application (PDF) |
Use this form to enroll your employees
and/or their dependents in Regence BlueCross BlueShield
Dental or Regence ValueCare Dental. |
| Dependent Child Certification (PDF) |
Verification of dependent eligibility form. |
| Affidavit of Qualifying Incapacitated Dependent Eligibility (Fillable PDF) |
Use this form to certify that an eligible dependent child is incapacitated due to medical disability, developmental disability or mental disorder. |
Enrollment Change Form
E-27 (PDF)
• English
(fillable PDF)
• Spanish |
Use this form when an employee experiences a life
change such as adding/deleting dependents, name
change or changes at open enrollment. (Complete
this PDF form online and print two copies. Sign
one form and send it in, save the second for your
records.) |
| Eligibility Adjustments (PDF) |
Use this form to calculate premium due when new enrollment, status changes or member cancellations have been made. |
| Group
Change Form (PDF) |
Use this form to cancel employees from a Regence
BlueCross BlueShield of Utah plan. In order for
current month’s changes to reflect on your
next billing, this form must be in our office no
later than 20 working days prior to the due date
of that billing. |
| Other
Insurance Information (PDF) (Coordination of Benefits) |
Employees who are covered under a
spouse’s health plan as well as a Regence
BlueCross BlueShield of Utah plan, or a Regence
HealthWise plan, or a Regence ValueCare plan should
complete this form and mail it to us. |
Special Enrollment Period (SEP)
Form (PDF)
• English
(fillable PDF)
• Spanish |
Use this form for new hires or for
adding individuals at times other than open enrollment.
Attached Health Questionnaire must accompany SEP
form. |
| COBRA/CONTINUATION
FORMS |
| COBRA
Booklet (PDF) |
Information you need to know about
COBRA. |
| COBRA, USERRA or STATE CONTINUATION Application (fillable PDF) |
Use this form when an employee or
dependent chooses to continue group coverage after
a qualifying event. |
| COBRA
Election Notice and Form (PDF) |
This notice contains important information
about the employee's right to continue health care
coverage, and an election form. |
| COBRA
General Notice (PDF) |
This is a model General Notice of
COBRA Continuation Coverage Rights for employees. |
| Early
COBRA Termination Notice (PDF) |
This is a sample Notice of Termination
of COBRA Continuation Coverage for employees. |
| Unavailability
of COBRA Notice (PDF) |
This is a sample Notice of Unavailability
of COBRA Continuation Coverage for employees. |
| AUTHORIZATION FORM |
Authorization to Disclose Protected Health Information
• English
• Spanish |
Authorization for Regence BlueCross
BlueShield of Utah to disclose health information to a
designated party for a specific purpose. |
PRESCRIPTION MEDICATION
MAIL-ORDER FORMS
Now located on the RegenceRx
Web site. |
| REIMBURSEMENT
FORMS |
| Member Reimbursement Claim Form (PDF) |
Use this form to submit claims for covered services, or prescription plans that require you to pay out of pocket and submit for reimbursement. |
| ADDITIONAL INFORMATION
REQUEST FORMS |
| Other
Insurance Information (PDF) (Coordination of Benefits
Report) |
Employees who are covered under a
spouse’s health plan as well as a Regence
BlueCross BlueShield of Utah plan, or a Regence
HealthWise plan, or a Regence ValueCare plan should
complete this form and mail it to us. |
| Incident
Report (PDF) |
Use this form to verify accident
information and third-party liability. |
| MEMBER NOTICES |
| Your
Special Enrollment Period Rights (PDF) |
You can request enrollment
for yourself or family members if eligibility with
other coverage is no longer in effect. |
| Notice
of Preexisting Condition Exclusion (PDF) |
This notice is for those
who have a preexisting medical condition. It details
the exclusion period and how to verify your prior
health insurance creditable coverage. |
