Forms for Additions, Changes, and Deletions

Small Businesses (1-100) | Large Groups (101+) | Continuity of Care | Miscellaneous | Specialty Benefits

Complete fillable PDFs online and then print, sign and submit them to Blue Shield. You will need Adobe Reader to complete the fillable form. If you do not have Adobe Reader or are not able to access these fillable features, download the latest version. We recommend using our online version where it is available.

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Small Businesses (1-100)

Form Purpose Download/
complete online
Refusal of Coverage
(C19927)
Employees should complete this form if they or their spouse/domestic partner of dependents are refusing their employer's medical or dental plan coverage. Refusal of Coverage (English)
(PDF, 567KB)
Subscriber Change Request
(C675-1)

This form should be used to report changes to employees' personal information or any type of coverage changes, such as adding or deleting dependents.

Log in to Employer Connection to make changes

Subscriber Change Request (English)
(PDF, 1.1MB)

Subscriber Change Request (Spanish)
(PDF, 1.3MB)

Multiple Subscriber Change Spreadsheet
(C50843-FF)
Use this form for making multiple subscriber-level plan changes at renewal. Multiple Subscriber Change Spreadsheet
(PDF, 115KB)
Employee Change/Cancellation Transmittal
(A36965)

Use this form to submit a monthly summary of employee changes to your existing members, such as adding or deleting dependents.

Log in to Employer Connection to make changes

Employee Change/Cancellation Transmittal
(PDF, 1.7MB)


Large Groups (101+)

Form Purpose Download/
complete online
Refusal of Coverage
(C13124)
Employees should complete this form if they or their spouse/domestic partner of dependents are refusing their employer's medical or dental plan coverage. Refusal of Coverage
(PDF, 215KB)
Subscriber Change Request
(C675-1-ML)

This form should be used to report changes to employees' personal information or any type of coverage changes, such as adding or deleting dependents.

Log in to Employer Connection to make changes

2022 Form 
Subscriber Change Request (English)
(PDF, 949KB)

Subscriber Change Request (Spanish)
(PDF, 972KB)

Subscriber Change Request (Chinese)
(PDF, 1.3MB)

Subscriber Change Request (Vietnamese)
(PDF, 1MB)

Subscriber Change Request (Persian)
(PDF, 958KB)

Employee Change/Cancellation Transmittal
(A36965)

Use this form to submit a monthly summary of employee changes to your existing members, such as adding or deleting dependents.

Log in to Employer Connection to make changes

Employee Change/Cancellation Transmittal
(PDF, 1.7MB)


Continuity of Care

Form Purpose Download
Request for Continuity of Care Services
(C13095)
Use this form for new and established enrollees to continue care with a current healthcare provider who is leaving the Blue Shield provider network.

Request for Continuity of Care Services (English)
(PDF, 1.33MB)
Request for Continuity of Care Services (Spanish)
(PDF, 1.28MB)
Request for Continuity of Care Services (Chinese)
(PDF, 1.65MB)
Request for Continuity of Care Services (Vietnamese)
(PDF, 1.36MB)
Request for Continuity of Care Services (Hindi)
(PDF, 1.4MB)

Request for Continuity of Care Services (Korean)
(PDF, 1.47MB)

 

Continuity of Care Brochure
(A11510)

Learn more about continuity of care services for new and existing members of a Blue Shield of California plan.

Continuity of Care Brochure (English)
(PDF, 1.22MB)
Continuity of Care Brochure (Spanish)
(PDF, 1.23MB)
Continuity of Care Brochure (Chinese)
(PDF, 1.62MB)
Continuity of Care Brochure (Vietnamese)
(PDF, 1.29MB)
Continuity of Care Brochure (Hindi)
(PDF, 1.32MB)

Continuity of Care Brochure (Korean)
(PDF, 1.41MB)

 


Miscellaneous

Form Purpose Download

Conversion to Individual Coverage Request
(A16170)

Use this form for employees who have held group coverage for three or more consecutive months and are eligible to transfer to an individual conversion plan when they retire, leave the job or become ineligible for group coverage.

Conversion to Individual Coverage Request
(PDF, 111KB)

All Group Information Update
(A44464)

Use this form to update billing address or contact information.

All Group Information Update
(PDF, 126KB)

Declaration of Disability for Over Age Dependent Children (C3674) Use this form for enrolled dependent children who would normally lose their eligibility under this plan solely because of age, but who are incapable of self-sustaining employment by reason of a physically or mentally disabling injury, illness or condition. Use Form C13125 "Full-time Student Certification" for dependents on a medical leave of absence from a college or trade school.

Declaration of Disability for Over Age Dependent Children
(PDF, 45KB)

Subscriber Statement of Disability
(C12198)
Use this form to file for an extension of benefits; employees must complete this form. In addition, the Benefit Administrator must complete and submit a Notice of Total and Permanent Disability.

Subscriber Statement of Disability
(PDF, 448KB)

Attending Physician Statement of Disability
(CP1012-LO)
Use this form to file for an extension of benefits. The employee's primary care physician must complete this form and submit it to Blue Shield. In addition, employees must complete a Subscriber Statement of Disability and a Notice of Total and Permanent Disability.

Attending Physicial Statement of Disability
(PDF, 456KB)

Medicare Prescription Drug Plan Disenrollment Opt-Out Form
(PDP00038)

Employees who are no longer under group coverage or have a reduction in benefits are eligible to convert their group life insurance coverage to an individual non-participating whole life insurance policy.

Medicare Prescription Drug Plan Disenrollment Opt-Out Form
(PDF, 17KB)

Medicare Prescription Drug Plan Disenrollment Opt-Out Form with remaining creditable Rx Coverage
(PDP00039)
Members should complete this form when they are opting out of their employer-sponsored coverage. After doing so they will still have creditable Rx coverage.

Medicare Prescription Drug Plan Disenrollment Opt-Out Form with remaining creditable Rx Coverage
(PDF, 90KB)


Specialty Benefits

Form Purpose Download

Conversion to Individual Policy from Group life Insurance
(CP1020)

Employees who are no longer under group coverage or have a reduction in benefits are eligible to convert their group life insurance coverage to an individual non-participating whole life insurance policy.

Conversion to Individual Policy from Group Life Insurance
(PDF, 96KB)

Life Insurance Beneficiary Change Request
(ABU1165)
To be used to designate/change beneficiaries

Life Insurance Beneficiary Change Request
(PDF, 455KB)

Authorization of Release of Personal Health Information
(A46163)

Authorization form for Blue Shield of California and/or Blue Shield of California Life & Health Insurance Company to Disclose Personal Health Information to a Third Party.

Authorization of Release of PHI (English)
(PDF, 119KB)
Authorization of Release of PHI (Spanish) 
(PDF, 121KB)
Authorization of Release of PHI (Chinese) 
(PDF, 347KB)
Authorization of Release of PHI (Vietnamese) 
(PDF, 248KB)
Authorization of Release of PHI (Hindi) 
(PDF, 154KB)

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