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RBG, PALM BEACH - FORMS
FLORIDA BLUE RELEASED DOWNLOAD
Employer Enrollment
*Renewal Only* Grandfathered Plan Cert Form

Description:
Renewal Only (pdf , 114k)

8/30/2013   Download
*Renewal Only* SG ER Amendment Form

Description:
Employer Amendment Form- Renewals Only (pdf , 132k)

9/5/2013   Download
LG/SG Enrollment Summary Form

Description:
SG-Renewals Only LG-NB and Renewals (pdf , 95k)

8/30/2013   Download
Quotes-LG Med Questionnaire (9582-1293/Rev.10/10

Description:
Required for NB Quote 51+ (pdf , 263k)

9/5/2013   Download
SG Electronic Initial Payment Authorization Form

Description:
e-pay form (pdf , 36k)

8/30/2013   Download
SG Group Medical Questionnaire 4-50 Lives

Description:
4 Enrolled - 50 Eligible (pdf , 146k)

8/30/2013   Download
SG New Business Checklist

Description:
Checklist of Required Forms (pdf , 271k)

8/30/2013   Download
SG/LG Health Equity Website Link

Description:
HSA/HRA/FSA Health Equity Link to forms (pdf , 50k)

8/30/2013   Download
Employee Enrollment
LG/SG Health Enrollment App (22095-0210R)

Description:
English Form (pdf , 373k)

8/30/2013   Download
LG/SG Spanish Health Enrollment App (22095-0210R)

Description:
Spanish Form (pdf , 1358k)

8/30/2013   Download
SG Individual Medical Questionnaire

Description:
Employee level medical questionnaire (pdf , 140k)

8/30/2013   Download
Administration
Benefit Admin Authorization Form (70265-1010)

Description:
Form req for Blue Biz, Blues enroll and View and Pay Invoice (pdf , 189k)

8/30/2013   Download
Health Change App Spanish (22411-0213)

Description:
Spanish Form (pdf , 232k)

8/30/2013   Download
Health Change Application (22411-0213)

Description:
English Form (pdf , 508k)

8/30/2013   Download
Claims
HIPPA Authorization Form
8/30/2013   Download
Medical Claim Form
8/30/2013   Download
Prime Mail Order Form
8/30/2013   Download