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Enrollment Spreadsheet |
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2022 - Q1 | Q2 | Q3 | Q4
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Guide to Enrollment Spreadsheet | Download | ||
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. As a reminder, once a fillable PDF is saved to the desktop, you cannot go back and make changes. |
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2023 Employee Application New/renewing groups effective July 1, 2023 |
English (Fillable PDF, 1.4 MB) Spanish (Fillable PDF, 1.6 MB) |
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2023 Employee Application New/renewing groups effective January 1, 2023 |
English (Fillable PDF, 1.4 MB) Spanish (Fillable PDF, 1.6 MB) |
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2022 Employee Application New/renewing groups effective October 1, 2022 |
English (Fillable PDF, 1.5 MB) Spanish (Fillable PDF, 876 KB) |
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2022 Employee Application New/renewing groups effective January 1 through September 30, 2022 |
English (Fillable PDF, 1.23 MB) Spanish (Fillable PDF, 1.46 MB) |
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Subscriber Change Request Employees can change personal information, change plans during open enrollment, enroll new dependents, or cancel dependents (please include the Refusal or Cancellation of Personal Coverage form). |
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2023 Subscriber Change Request New/renewing groups effective July 1, 2023 |
English (Fillable PDF, 1.3 MB) Spanish (Fillable PDF, 1.4 MB) |
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2023 Subscriber Change Request New/renewing groups effective January 1, 2023 |
English (Fillable PDF, 1.2 MB) Spanish (Fillable PDF, 1.4 MB) |
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2022 Subscriber Change Request New/renewing groups effective October 1, 2022 |
English (Fillable PDF, 1.2 MB) Spanish (Fillable PDF, 1.15 MB) |
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2022 Subscriber Change Request New/renewing groups effective January 1 through September 30, 2022 |
English (Fillable PDF, 1.2 MB) Spanish (Fillable PDF, 1.15 MB) |
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Refusal of Coverage Employees complete this form if they, their spouse/domestic partner, or other dependents refuse their employer’s medical or dental plan coverage |
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2023 Refusal of Coverage form New/renewing groups effective July 1, 2023 |
English (Fillable PDF, 765 KB) Spanish (Fillable PDF, 881 KB) |
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2023 Refusal of Coverage form New/renewing groups effective January 1, 2023 |
English (Fillable PDF, 764 KB) Spanish (Fillable PDF, 880 KB) |
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2022 Refusal of Coverage form New/renewing groups effective October 1, 2022 |
English (Fillable PDF, 756 KB) Spanish (Fillable PDF, 876 KB) |
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2022 Refusal of Coverage form New/renewing groups effective January 1, 2022 |
English (Fillable PDF, 567 KB) | ||
Continuity of Care program brochure | English Spanish Chinese Vietnamese Hindi Korean |
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Request for Continuity of Care Service for established members and new enrollees Members of HMO-only groups with qualifying conditions may be able to complete care with a non-network provider. |
English Spanish Chinese Vietnamese Hindi Korean |
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Authorization for the use or disclosure of health information | English Spanish Chinese Vietnamese Hindi Korean |
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Declaration of Disability of Over-Age-Dependent Children For enrolled dependent children who normally lose their eligibility because of age but who have a physical or mental disabling injury. |
English Spanish |
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Waiver of Premium Claim Form – Life |
Download | ||
Premium Only Plan (POP) HealthEquity's POP lets employers cut payroll taxes without cutting payroll. If an employer requires employees to contribute to the cost of their insurance, a Section 125 POP allows them to do so with pre-tax dollars. |
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CVS Mail Order Form | 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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Health insurance products are offered by Blue Shield of California Life & Health Insurance Company. Health plans are offered by Blue Shield of California.