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RBG, TAMPA-FT. MYERS - FORMS
FLORIDA BLUE RELEASED DOWNLOAD
Employer Enrollment
Commission Acknowledgement Letter

Description:
Required for new large groups and large group renewals. (ocx , 34k)

1/27/2016   Download
EFT Form

Description:
For initial payments. (pdf , 76k)

1/27/2016   Download
Employer App - all products

Description:
Master app for all lines of coverage (pdf , 396k)
Version: 23845P-0813R

11/6/2014   Download
Employer Application - medical only

Description:
Small group Employer Application (pdf , 61k)
Version: 20741-0613R SR

11/6/2014   Download
Large Group Underwriting Questionnaire 100+
1/27/2016   Download
Large Group Underwriting Questionnaire 51+
2/7/2017   Download
Employee Enrollment
Employee Application

Description:
Employee enrollment/waiver form for all BCBS coverages (pdf , 248k)
Version: 22095 0914R SR

1/29/2015   Download
Employee Application - Spanish

Description:
Spanish version of Employee enrollment for all BCBS medical coverages (pdf , 112k)
Version: 22095S - 0210

6/17/2010   Download
Employee Change Form

Description:
Make changes/terminations for all BCBS health products (pdf , 227k)
Version: 22411-0813R SR

1/16/2015   Download
Employee Change Form - Spanish

Description:
Make changes/terminations for all BCBS health products (pdf , 232k)
Version: 22411S-0813 SR

11/4/2014   Download
Administration
Amendment

Description:
Use this form to change group name, plan, waiting period, contribution, etc. (pdf , 102k)
Version: 20752-0613

11/4/2014   Download
ATNE

Description:
To Calculate Average Total # of Employees (pdf , 104k)

11/6/2014   Download
Common Ownership Form

Description:
For Single Employers (pdf , 44k)
Version: 62891-0613 SR

11/4/2014   Download
Enrollment Summary

Description:
This form should be completed for all renewals, As Is or otherwise. (pdf , 67k)
Version: 7823 SR 0613

11/4/2014   Download
Grandfathered Plan Certification

Description:
A group health plan that existed on the date of March 23, 2010. (pdf , 105k)
Version: 73060-0512

11/4/2014   Download
Claims
Appeal Claim form HMO
11/6/2014   Download
Appeal Claim Form Non-HMO
11/6/2014   Download
International Claim Form

Description:
BlueCard Worldwide International Claim Form (PDF , 744k)
Version: N13-04-086

1/27/2010   Download
Medical Claim Form
1/27/2016   Download
Prescription Claim Form
3/4/2016   Download
Other
2017 HSA Trifold
2/7/2017   Download
2017 RBG New Census Template
2/7/2017   Download
Small Group Underwriting Guidelines
4/15/2016   Download
Summary of Benefits and Coverage

Description:
The purpose of the SBC is to provide employers and employees with standard information, so they can more easily compare plans and make an informed choice about coverage plan options. ( , 0k)
For more information: Click Here

10/24/2012   Website