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RBG, SAN JOSE - FORMS
BLUE SHIELD OF CALIFORNIA RELEASED DOWNLOAD
Employer Enrollment
Attestation Form

Description:
For Groups with 10+ EE's (pdf , 49k)

10/10/2016   Download
Blue Shield Health and Wellness Link
4/26/2016   Download
Checklist 2016
4/26/2016   Download
Electronic Funds Transfer - Check by Fax
4/26/2016   Download
Master Group Application
10/10/2016   Download
Master Group Application - 1/1/2017
10/17/2016   Download
Request for Contract Change 10/1/2016
10/10/2016   Download
Sole Proprietor or Corporate Officer Statement 201
4/7/2016   Download
Employee Enrollment
Employee Enrollment Application - 1/1/2017
10/17/2016   Download
Employee Enrollment Form 10/1/16
10/10/2016   Download
PHI Authorization Form
4/28/2016   Download
Spanish Employee Application 2016
10/10/2016   Download
Subscriber Change Request Form 1/1/2016
3/9/2016   Download
Administration
Administration Guide - 2016
4/7/2016   Download
Cal-COBRA Election Form
4/26/2016   Download
Cal-COBRA Election Form After Federal COBRA
4/26/2016   Download
Cal-COBRA Take Over Form

Description:
New Blue Shield Groups should use this form for Cal-COBRA employees who were covered by your previous healthcare carrier (pdf , 74k)
Version: C14755

4/26/2016   Download
COBRA Application
4/26/2016   Download
Employee Cancellation Transmittal
4/26/2016   Download
Notification of Qualifying Event Cal-COBRA

Description:
Complete this form when covered employees have an event that qualifies them for coverage under Cal-COBRA. Blue Shield will send information on benefits, rates and enrollment to eligible employees within 14 days of receiving the form. (pdf , 64k)

4/11/2016   Download
Claims
Blue Shield RX Search Link
4/26/2016   Download
Dental Claim Form
4/26/2016   Download
Medical Claim Form (Subscriber's State of Claim)
4/27/2016   Download
Medical Clain Form - Blue Shield Life
4/17/2013   Download
Pharmacy Reimbursement Claim Form
4/27/2016   Download
RX Mail Order Claim Form (PrimeMail)
4/27/2016   Download
Vision Claim Form (MES)
4/27/2016   Download
Other
Blue Shield Producer Agreement
2/5/2010   Download
Blue Shield Provider Search Link
4/26/2016   Website