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RBG, JACKSONVILLE - FORMS
FLORIDA BLUE RELEASED DOWNLOAD
Employer Enrollment
New Case - Sm Group - Employer Paperwork

Description:
An all-in-one packet of all commonly required items for a new small group case. (4-50 lives) (pdf , 941k)

1/16/2017   Download
Renewal - Conversion Report

Description:
Used on renewals that involve a plan change. Easily designate which members will take which plan. (xls , 245k)

8/17/2009   Download
Renewal - Enrollment Summary

Description:
Required for all BCBS Renewals (pdf , 49k)

12/30/2014   Download
Renewal - Sm Group - Amendment Application

Description:
Use the amendment application to report your group level changes such as plan changes and wait period changes. This form may also be used throughout the plan year for other group level changes. (pdf , 102k)

12/30/2014   Download
Employee Enrollment
AFFIDAVIT OF DOMESTIC PARTNERSHIP

Description:
BCBSFL Affidavit of Domestic Partnership (pdf , 247k)

3/21/2010   Download
BCBS Employee Change Application

Description:
Employee Change Application (pdf , 227k)

12/30/2014   Download
BCBS Employee Enrollment Application

Description:
Employee Enrollment Application (pdf , 248k)

2/3/2016   Download
FCL Life & Dental Employee Enrollment Application

Description:
FCL Dental/Life/ AD&D/ Disability Employee Enrollment Application (pdf , 396k)

12/30/2014   Download
Administration
Agent of Record Letter

Description:
Template for Agent of Record (AOR)changes. Also Includes RBG Servicing Agent Appointment. (doc , 27k)

7/16/2009   Download
Benefit Administrator Authorization Form

Description:
BA authorization form is needed for access to BlueBiz, BluesEnroll & View an Pay Invoice (VPI). Please note: There may only be one Decision Maker (DM) per group. (pdf , 189k)

12/30/2014   Download
Claims
BCBS Major Medical Claim Form

Description:
Used by members who need to submit a medical claim directly to BCBSF (pdf , 170k)

12/30/2014   Download
BCBSFL PrimeMail Pharmacy Form

Description:
Blue Cross and Blue Shield Mail Order Pharmacy Form (pdf , 251k)

12/30/2014   Download
Dental Claim Form

Description:
Used by members who need to submit a dental claim. Must be accompanied by a detailed bill. (pdf , 343k)

7/17/2009   Download
Rx Claim

Description:
Used to request reimbursement for Rx (pdf , 644k)

12/30/2014   Download
Other
Medication Guide July 2015 - Closed Formulary
7/23/2015   Download
Medication Guide July 2015 - Open Formulary
7/23/2015   Download