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Request for Continuity of Care English
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Continuity of Care Notice
Important notice for new HMO enrollees
English
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Continuity of Care Flyer English
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Chinese 
Vietnamese

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Authorization for the Use or Disclosure of Health Information English
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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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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).

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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).

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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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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. 

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