Forms
Broker authorization forms
- Broker of Record Letter TemplateOpen a PDF
- Letter of Authorization TemplateOpen a PDF
- Letter of Consultation TemplateOpen a PDF
- RX Only - Letter of Consultation TemplateOpen a PDF
- Broker Access for Web Enrollments & Updates
Broker web account consolidation
Group underwriting forms
- New Group Paperwork
- Renewal Group Paperwork
- Healthy New York RecertificationOpen a PDF
- Healthy NY Eligibility Policy FormOpen a PDF
Prescription claims forms
Claims forms
- $300 BlueHealthy Dollars Reimbursement FormOpen a PDF
- Blue Healthy Choices Lifestyle Benefits Reimbursement FormOpen a PDF
- Dental Claim FormOpen a PDF
- Medical Claim FormOpen a PDF
- SimplyBlue Gym Membership Incentive Reimbursement FormOpen a PDF
- Flexible Spending Account or Medical Reimbursement Account Forms
Eligibility certification forms
- Adoption or Foster Dependent FormOpen a PDF
- Away From Home Care Guest Membership ApplicationOpen a PDF
- Continuing Coverage for Students on Medical Leave FormOpen a PDF
- Dependent Certification FormOpen a PDF
- Adult Disabled Dependent FormOpen a PDF
- Domestic Partner Affidavit FormOpen a PDF
- Employer Setup Form for Integrated HSAOpen a PDF
- Qualified Medical Child Support Order Certification FormOpen a PDF
- Young Adult Option Certification FormOpen a PDF
- ARPA COBRA Subsidy Attestation FormOpen a PDF
- Medicare Eligibility Form for Commercial PlansOpen a PDF
Medical and dental enrollment forms for groups with 101+ full-time equivalent employees
Forms for Small Groups (100 or fewer), Individuals, and Families are available in Blue on Demand (Login Required)
Forms for Small Groups (100 or fewer), Individuals, and Families are available in Blue on Demand
- Choose application based on whether the product requires a primary care physician
- Select the plans your group offers from the dropdown(s) under Medical and Dental Plan Selection
- PPO/EPO/Indemnity - No Primary Care Physician (PCP)Open a PDF
- POS/HMO - Requires Primary Care Physician (PCP)Open a PDF
Additional enrollment forms
- Additional Dependent AddendumOpen a PDF
- Membership Cancellation WorksheetOpen a PDF
- Vision Enrollment FormOpen a PDF
