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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. |
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| 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 |
|---|---|
| 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 |
Contact Us
Producer Services (800) 559-5905
Employer Services (800) 325-5166
Blue Shield of California
PO Box 272540
Chico, CA 95927-2540
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© California Physicians’ Service DBA Blue Shield of California 1999-. All rights reserved. California Physicians’ Service DBA Blue Shield of California is an independent member of the Blue Shield Association.
Health insurance products are offered by Blue Shield of California Life & Health Insurance Company. Health plans are offered by Blue Shield of California.