Blue Cross of Idaho Forms

Group Forms 1. Application for Medium/Large Employer Coverage (51 or more) 2. Application for Small Employer Coverage (2-50 Employees) 3. BC Large Group w/o Health Statement 4. Deductible Dental Brochure / Incentive Dental Brochure 5. Employee Waiver of Health Care Coverage 6. Group Questionnaire for New Groups (2-50 employees) 7. Group Stand Alone Dental Application 8. Large Group Application with Health Statement 9. Large Group Health/Dental Application w /o Health Statement 10. Large Group Health/Dental Enrollment Application with Health Statement 11. Large Group Questionnaire for New Groups (51 or more) 12. Patient Questionnaire Claim Form 13. Preferred Dental Brochure 14. Prescription Drug Reimbursement Form 15. Small Group Enrollment Application 16. Vision Service Plan Options 17. Voluntary Dental Application (Employer) 18. Voluntary Dental Sales Literature

Individual Forms 19. Authorization Agreement for Prearranged Payments 20. BlueCare PPO Brochure 21. Dental Blue PPO Rates 22. Dental Blue PPO Sales Literature and Application 23. Dental PPO Application (Individual) 24. Essential Blue Basic PPO Brochure 25. Essential Blue Plus PPO Brochure 26. HSA Blue Sales Literature 27. Individual Application & Cover Sheet 28. Individual Application Checklist 29. Individual Health Insurance Coverage Change Form 30. Individual Program Premiums - all levels 31. Latitude Brochure & Talking Points 32. Medicare Advantage Plans Enrollment Form (Seniors) 33. Medicare Supplement Application - Plan J 34. Medicare Supplement Application - Plans A,C, & F 35. Patient Questionnaire Claim Form 36. Personal Blue Sales Literature 37. Prescription Drug Reimbursement Form 38. Short Term Brochure and Application 39. Short Term Rates & Benefits 40. Simply Blue Brochure 41. Simply Blue Premiums - all levels 42. Transfer Application