Forms and applications
When providing an application to an applicant or Blue Shield member, you must also include a Notice of Language Assistance.
Broker plan comparison tool
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Employer forms and applications
Fillable PDFs can be saved to your desktop. However, applicants using Acrobat Reader, rather than Acrobat Standard or Pro, will only be able to print the information after it's filled out, not save. If using Standard or Pro, the filled out information can be saved. If you do not have Adobe Reader or are not able to access these fillable features, download the latest version.
| Form | Download |
|---|---|
Note: Microsoft Edge is not recommended for viewing or downloading these forms. |
Effective 1/1/2024 Effective 1/1/2023 Effective 1/1/2022 |
| Welcome letter and checklist Use this customizable employer welcome letter and checklist to help simplify the enrollment process. |
Download (Fillable PDF) |
| Subscriber change request Employees can change personal information, change plans during open enrollment, enroll new dependents or cancel dependents (include Refusal or Cancellation of Personal Coverage form). |
Effective 1/1/2024 Effective 1/1/2023 Effective 1/1/2022 |
| Employee change/cancellation transmittal Submit a monthly summary of employee cancellations and/or changes. |
Download (Fillable PDF, 1.3 MB) |
| Employer questionnaire | Download (Fillable PDF, 533 KB) |
Employee forms and applications
Fillable PDFs can be saved to your desktop. However, applicants using Acrobat Reader, rather than Acrobat Standard or Pro, will only be able to print the information after it's filled out, not save. If using Standard or Pro, the filled out information can be saved. If you do not have Adobe Reader or are not able to access these fillable features, download the latest version.
| Form | Download |
|---|---|
| Employee application Employees should complete this form to enroll in a group medical plan. For employee enrollments to a new or existing employer group. |
|
| Medical only employee application Employees should complete this form to enroll in a group medical plan. For employee enrollments to a new or existing employer group. |
Effective 1/1/2024 Effective 1/1/2023 Effective 1/1/2022 |
| Life only employee application Employees should complete this form to enroll in a group term life policy. For employee enrollments to a new or existing employer group. |
Effective 1/1/2024 Effective 1/1/2023 Effective 1/1/2022 |
| Medical and Life employee application Employees should complete this form to enroll in a group medical plan, group vision plan or group term life policy. For employee enrollments to a new or existing employer group. |
Effective 1/1/2024 Effective 1/1/2023 Effective 1/1/2022 |
| Form | Download |
|---|---|
| Evidence of Insurability | Download (PDF, 188 KB) |
| Refusal of Personal Coverage Form Employees should complete this form if they, their spouse/domestic partner of dependents are refusing their employer's medical or dental plan coverage. |
Download (PDF, 567 KB) |
| Declaration of Disability of Over Age Dependent Children For enrolled dependent children who normally lose their eligibility because of age, but who are disabled by reason of a physically or mentally disabling injury. |
English (PDF, 88 KB) Spanish (PDF, 173 KB) |
| Subscriber disability File for an extension of benefits. Administrators must also complete the Notice of Total and Permanent Disability Form. |
Download (PDF, 91 KB) |
| Disability Addendum | Download (PDF, 86 KB) |
| Authorization for the Release of Health Information | Download (PDF, 119 KB) |
Specialty benefits
| Form | Download |
|---|---|
| Conversion to Individual Coverage: Group Life | Download (PDF, 117 KB) |
| Beneficiary Affidavit & Assignment Form | Download (PDF, 119 KB) |
| Beneficiary Change Request | Download (PDF, 77 KB) |
| Waiver of Premium Claim Form: Group Life If a member becomes totally disabled, the life premium may be waived |
Download (PDF, 550 KB) |
Additional Contact Designation Form: Notice of Lapse or Termination of Life Insurance Policy for Non-Payment of Premium |
Download (PDF, 511 KB) |
Continuity of Care
| Form | Download |
|---|---|
| Request for Continuity of Care | English (PDF, 99 KB) Spanish (PDF, 628 KB) Chinese (PDF, 726 KB) Vietnamese (PDF, 762 KB) Hindi (PDF, 790 KB) Korean (PDF, 692 KB) |
| Authorization for the Use or Disclosure of Health Information | English (PDF, 119 KB) Spanish (PDF, 117 KB) Chinese (PDF, 198 KB) Vietnamese (PDF, 217 KB) Hindi (PDF, 229 KB) Korean (PDF, 167 KB) |
Claim forms
| Form | Download |
|---|---|
| Subscriber's Statement of Claim | Download (PDF, 103 KB) |
| American Specialty Health (ASH) – Subscriber Claim Form | Download (PDF, 420 KB) |
| Out of State Claim Form | Download (PDF, 99 KB) |
| Authorization for Release of Personal and Health Information | Download (PDF, 119 KB) |
| Pharmacy Reimbursement | Download English (PDF, 221 KB), Download Spanish (PDF, 1.5 MB) |
| Beneficiary Change Request | Download (PDF, 77 KB) |
| Blue Shield Global Core International Claim | Download (PDF, 138 KB) |
| Proof of Death Form: Group Life | Download (PDF, 140 KB) |
| Accelerated Death Benefit Claim Form: Group Life | Download (PDF, 108 KB) |
| Dismemberment Claim Form: Group Life | Download (PDF, 555 KB) |
| Dental Claim | Download (PDF, 168 KB) |
| Vision Claim | Download (PDF, 592 KB) |
COBRA / Cal-COBRA
| Form | Download |
|---|---|
Continuation of Coverage Application (COBRA and Cal-COBRA) |
Download (Fillable PDF, 187 KB) |
Employer Notification of Qualifying Events under Cal-COBRA |
Download (Fillable PDF, 57 KB) |
Cal-COBRA Take-Over |
Download (Fillable PDF, 100 KB) |
Cal-COBRA Election Form This form is for members to enroll in Cal-COBRA is they have exhausted their Federal Cal-COBRA coverage, are not eligible for Federal Cal-COBRA coverage due to their employer's type of coverage, or are moving from another carrier's Cal-COBRA policy to a Cal-COBRA policy under Blue Shield. |
Download (Fillable PDF, 144 KB) |
Notice informing individuals about nondiscrimination and accessibility requirements
