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Request for Continuity of Care Service for established members and new enrollees. English*
Spanish
Chinese
Vietnamese
Hindi
Korean
Continuity of Care Notice
Important notice for new HMO enrollees
English
Spanish
Chinese 
Vietnamese
Continuity of Care Flyer English
Spanish
Chinese 
Vietnamese

Hindi
Korean
Authorization for the Use or Disclosure of Health Information English
Spanish
Chinese
Vietnamese
Hindi
Korean
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Subscriber's Statement of Claim Download 
Statement of Claim: Blue Shield Life Download
Authorization for Release of Personal and Health Information Download
Pharmacy Reimbursement Download
Blue Shield Global Core International Claim Download 
Proof of Death Form: Group Life Download
Accelerated Death Benefit Claim Form: Group Life Download
Dismemberment Claim Form: Group Life Download
Dental Claim Download
Vision Claim Download
Waiver of Premium Claim Form: Group Life
If a member becomes totally disabled, the life premium may be waived.
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COBRA Employee Application English
Spanish
Chinese
Vietnamese
Employer Notification of Qualifying Events under Cal-COBRA (ENF)
Complete this form when covered employees have an event that qualifies them for coverage under
the California Continuation Benefits Replacement Act (Cal-COBRA, California Senate Bill 719)
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Cal-COBRA Take-Over
New groups should use this form when changing carriers to Blue Shield for Cal-COBRA members
covered under a previous carrier. Employers are responsible for notifying their Cal-COBRA
members of the transition to a new carrier and Cal-COBRA members are required fill out the form
and submit to the Cal-COBRA team within 30 days of transition.
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Continuing Group Coverage after Federal COBRA Cal-COBRA Election
After exhausting 18
months of Federal COBRA benefits, a beneficiary may be eligible to an 18-month extension through Cal-COBRA. Beneficiary must contact Cal-COBRA (800) 228-9476 to
request the extension and ensure they meet the requirements. If approved, the beneficiary will
submit this form to formally accept the extension
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Cal-COBRA Election
Once the employer submits the ENF, an Election packet is sent to the beneficiary. The election form
is completed by the beneficiary stating who is accepting coverage and plan choice. The election
form should be submitted
to Cal-COBRA for processing. NOTE: This form cannot be submitted without employer first submitting the ENF.
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Cal-COBRA Dental Election
For dental only groups: Once the employer submits the ENF, an Election packet is sent to the
beneficiary. The election form is completed by the beneficiary stating who is accepting coverage and
plan choice. The election form should be submitted to Cal-COBRA for processing. NOTE: This form cannot be
submitted without employer first submitting the ENF.
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