employer connection

Forms for Additions, Changes and Deletions

Small Businesses (1-50) |  Large Groups (51+)  |  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.

Get additional forms: 

Enrollment  |  Claims

 
Small Businesses (1-50)

FormPurposeDownload/
complete online
Refusal of Coverage
(C19927)
This form should be completed and submitted when eligible employees are refusing the employer's Blue Shield of California/Blue Shield of California Life & Health Insurance Company health plan coverage for themselves and/or their spouse, domestic partner, or dependent(s) if applicable.Download PDF (English)
(PDF, 101KB)
Download PDF (Spanish)
(PDF, 72KB)
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

  • 2015 Form
    Use for all changeseffective on or after January 1, 2014.

  • 2014 Form:
    Use for all changes between January 1 - December 31, 2014.

  • 2013 Form:
    Use for all changed in 2013 plan year, and for grandmothered plans. .

Log in to make changes

2015 Form
Download PDF (English)
(PDF, 171KB)
Download PDF (Spanish)
(PDF, 342KB)

2014 Form 
Download PDF (English)
(PDF, 221KB)

2013 Form
Download PDF (English)
(PDF, 250KB)
Download PDF (Spanish)
(PDF, 147KB)

Employee Change/Cancellation Transmittal
(C3843)

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

Log in to make changes 

Download PDF
(PDF, 65KB)

 
Large Groups (51+)

FormPurposeDownload/
complete online
Refusal of Coverage
(C13124)
This form should be completed and submitted when eligible employees are refusing the employer's Blue Shield of California/Blue Shield of California Life & Health Insurance Company health plan coverage for themselves and/or their spouse, domestic partner, or dependent(s) if applicable.Download PDF (English)
(PDF, 67KB)
Download PDF (Spanish)
(PDF, 79KB)
Download PDF (Chinese)
(PDF, 109KB)
Download PDF (Vietnamese)
(PDF, 136KB)
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

  • 2015 Form:
    Use for all changes effective after your 2015 renewal.

  • 2014 Form:
    Use for 2014 plan year, and all changes effective prior to your 2015 renewal.

Log in to make changes 

2015 Form
Download PDF (English)
(PDF, 194KB)

2014 Form
Download PDF (English)
(PDF, 118KB)
Download PDF (Spanish)
(PDF, 139KB)
Download PDF (Chinese)
(PDF, 270KB)
Download PDF (Vietnamese)
(PDF, 235KB)                                    

Employee Change/Cancellation Transmittal
(C3843)

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

Log in to make changes 

Download PDF
(PDF, 65KB)

 
Continuity of Care

FormPurposeDownload
Request for Continuity of Care Service for new enrollees
(C13095)
Use this form for new enrollees of HMO-only groups with qualifying conditions may be able to complete care with a non-network provider.

Download PDF (English)
(PDF, 68KB) 
Download PDF (Spanish)
(PDF, 50KB)
Download PDF (Chinese)
(PDF, 399KB)
Download PDF (Vietnamese)
(PDF, 176KB)

Request for Continuity of Care Service for established members
(C15712)

Use this form for established members (i.e. not new enrollees) of underwritten plans who are receiving care for a serious medical condition when the contracted provider leaves the Blue Shield network of providers.

Download PDF (English)
(PDF, 70KB)
Download PDF (Spanish)
(PDF, 155KB)
Download PDF (Chinese)
(PDF, 196KB)
Download PDF (Vietnamese)
(PDF, 212KB)

Continuity of Care Notice
(A11511)

Important notice for new HMO enrollees

Download PDF (English)
(PDF, 49KB)
Download PDF (Spanish)
(PDF, 58KB)
Download PDF (Chinese)
(PDF, 240KB)
Download PDF (Vietnamese)
(PDF, 281KB)

 
Miscellaneous

FormPurposeDownload

Conversion to Individual Coverage Request
(A16170)

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

Download PDF
(PDF, 111KB)

All Group Information Update
(A44464)

Use this form to update billing address or contact information.

Download PDF
(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.

Download PDF
(PDF, 45KB)

Subscriber Statement of Disability
(C12198)

This form must be completed by the employee. In addition, the Benefit Administrator must complete a Notice of Total and Pemanent Disability.

Download PDF
(PDF, 448KB)

Attending Physician Statement of Disability
(CP1012-LO)
Use this form to file for an extension of benefits. The employee's personal physician must complete this form and submit it to Blue Shield. In addition, employees must complete a Subscriber Statement of Disability (PDF, 447KB).

Download PDF
(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.

Download PDF
(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, but after doing so they will still have creditable Rx coverage.

Download PDF
(PDF, 90KB)

 Specialty Benefits

FormPurposeDownload

Conversion to Individual Policy from Group life Insurance
(CP1020)

To be used by employees who are no longer under group coverage, or who have a reduction in benefits, are eligible to convert their group life insurance coverage to an individual, non-participating, whole-life insurance policy.

Download PDF
(PDF, 96KB)

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

Download PDF
(PDF, 455KB)

Authorization of Release of Personal Health Information
(C15625)

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.

Download PDF
(PDF, 453KB)