Forms and Applications

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Get a quote | Web based enrollment | Medical plans | January 2024 Summary of Benefits | Prescription Drug Options

When providing an application to an applicant or Blue Shield member, you must also include a Notice of Language Assistance.

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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, 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
Master Group Application Note: Microsoft Edge is not recommended for viewing or downloading these forms.	Effective 1/1/2024 English (Fillable) 1.4 MB Spanish (Fillable) 1.3 MB Chinese (Fillable) 2.4 MB Vietnamese (Fillable) 2.1 MB Persian (Fillable) 2.3 MB Effective 1/1/2023 English (Fillable) 1.3 MB Spanish (Fillable) 697 KB Chinese (Fillable) 863 KB Vietnamese (Fillable) 815 KB Persian (Fillable) 815 KB Effective 1/1/2022 English (Fillable) 1.8 MB Spanish (Fillable) 1.5 MB Chinese (Fillable) 2.2 MB Vietnamese (Fillable) 1.8 MB Persian (Fillable) 1.6 MB
Welcome letter and checklist Use this customizable employer welcome letter and checklist to help simplify the enrollment process.	Download (Fillable)
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 English (Fillable) 1.1 MB Spanish (Fillable) 1.2 MB Chinese (Fillable) 1.4 MB Vietnamese (Fillable) 1.3 MB Persian (Fillable) 1.4 MB Effective 1/1/2023 English (Fillable) 545 KB Spanish (Fillable) 551 KB Chinese (Fillable) 733 KB Vietnamese (Fillable) 561 KB Persian (Fillable) 691 KB Effective 1/1/2022 English (Fillable) 948 KB Spanish (Fillable) 972 KB Chinese (Fillable) 691 KB Vietnamese (Fillable) 1 MB Persian (Fillable) 957 KB
Employee Change/Cancellation Transmittal Submit a monthly summary of employee cancellations and/or changes.	Download
Employer Questionnaire	Download (Fillable)

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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 English (Fillable) 583 KB Spanish (Fillable) 608 KB Chinese (Fillable) 790 KB Vietnamese (Fillable) 767 KB Persian (Fillable) 781 KB Effective 1/1/2023 English (Fillable) 904 KB Spanish (Fillable) 1.5 MB Chinese (Fillable) 1.8 MB Vietnamese (Fillable) 1.6 MB Persian (Fillable) 1.7 MB Effective 1/1/2022 English (Fillable) 1.4 MB Spanish (Fillable) 1.8 MB Chinese (Fillable) 1.4 MB Vietnamese (Fillable) 1.5 MB Persian (Fillable) 1.4 MB
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 English (Fillable) 452 KB Spanish (Fillable) 460 KB Chinese (Fillable) 613 KB Vietnamese (Fillable) 541 KB Persian (Fillable) 615 KB Effective 1/1/2023 English (Fillable) 764 KB Spanish (Fillable) 1.2 MB Chinese (Fillable) 1.6 MB Vietnamese (Fillable) 1.3 MB Persian (Fillable) 1.4 MB Effective 1/1/2022 English (Fillable) 1.2 MB Spanish (Fillable) 1.2 MB Chinese (Fillable) 1.5 MB Vietnamese (Fillable) 1.3 MB Persian (Fillable) 1.2 MB
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 English (Fillable) 1 MB Spanish (Fillable) 640 KB Chinese (Fillable) 821 KB Vietnamese (Fillable) 725 KB Persian (Fillable) 806 KB Effective 1/1/2023 English (Fillable) 938 KB Spanish (Fillable) 1.5 MB Chinese (Fillable) 1.9 MB Vietnamese (Fillable) 1.6 MB Persian (Fillable) 1.7 MB Effective 1/1/2022 English (Fillable) 1.4 MB Spanish (Fillable) 1.4 MB Chinese (Fillable) 1.8 MB Vietnamese (Fillable) 1.5 MB Persian (Fillable) 1.4 MB

Form	Download
HIPPAA Release Form Authorization for the release of personal and health information.	Download
Evidence of Insurability	Download
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
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 Spanish
Subscriber Disability File for an extension of benefits. Administrators must also complete the Notice of Total and Permanent Disability Form.	Download
Disability Addendum	Download
Authorization for the Release of Health Information	Download

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Form	Download
Standalone Specialty Benefits Employer Application Dental, Vision & Life Insurance	Download
Conversion to Individual Coverage: Group Life	Download
Beneficiary Affidavit & Assignment Form	Download
Beneficiary Change Request	Download
Waiver of Premium Claim Form: Group Life If a member becomes totally disabled, the life premium may be waived	Download

Form	Download
Request for Continuity of Care	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

Form	Download
Subscriber's Statement of Claim	Download
American Specialty Health (ASH) – Subscriber Claim Form	Download
Out of State Claim Form	Download
Authorization for Release of Personal and Health Information	Download
Pharmacy Reimbursement	Download
Beneficiary Change Request	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

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Form	Download
Continuation of Coverage Application (COBRA and Cal-COBRA) For existing groups requesting effective dates of October 1, 2020, and later, this form replaces the "COBRA Continuation of Coverage Application”, the “Cal-COBRA Election”, the "Cal-COBRA Dental Election", and the “Continuing Group Coverage After Federal COBRA” forms. Use this form to apply for a continuation of coverage (federal COBRA or Cal-COBRA).	Download (Fillable PDF)
Employer Notification of Qualifying Events under Cal-COBRA This form replaces the “Employer Notification of Qualifying Events under Cal-COBRA (ENF)” form for groups requesting changes effective October 1, 2020, and later. Complete this form each time a covered employee has a qualifying event that causes them to be eligible for continuation coverage under the California Continuation Benefits Replacement Act (Cal-COBRA).	Download (Fillable PDF)
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.	Download (Fillable PDF)