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Enrollment Spreadsheet |
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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 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 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 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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| Continuity of care notice for new HMO enrollees Important notice for new HMO enrollees. |
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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 (Fillable PDF) | ||
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 1999-2022. 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.