Forms & Documents
- Medical Claim FormOpen a PDF
- Dental Claim FormOpen a PDF
- Prescription Drug Claim FormOpen a PDF
- BlueHealthy Dollars Reimbursement FormOpen a PDF
- BlueHealthy Choices Lifestyle Benefits Reimbursement FormOpen a PDF
- SimplyBlue Gym Membership Incentive Reimbursement FormOpen a PDF
- Flexible Spending Account or Medical Reimbursement Account Forms
- Adoption or Foster Dependent FormOpen a PDF
- Adult Disabled 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 (Student Verification) FormOpen a PDF
- Domestic Partner Affidavit FormOpen a PDF
- Medicare Eligibility Form for Commercial PlansOpen a PDF
- Qualified Medical Child Support Order Certification FormOpen a PDF
- Qualified Medical Child Support Order Disenrollment FormOpen a PDF
- Young Adult Option Certification (Dependent Age 29) FormOpen a PDF
Large group medical and dental enrollment forms (101+ full-time equivalent employees)
- 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
Medicare enrollment forms
- 2027 Medicare Supplement Enrollment FormOpen a PDF
- 2027 Medicare Supplement Group Enrollment FormOpen a PDF
- 2026 Medicare Supplement Enrollment FormOpen a PDF
- Excellus BCBS HMO / PPO / Medicare Supplement Disenrollment
- Enroll, change or cancel coverage for a Medicare Advantage or Medicare Supplemental member
2027 Group enrollment applications
- Medicare Blue Choice (HMO-POS) / Medicare Blue PPO - Rochester Region
- Medicare PPO - All Other Regions
2026 Group enrollment applications
Medical sales tools and resources
At-a-glance products and benefits*
Rochester region
Syracuse region
Albany, Mid-Hudson, Utica region
Member brochures
Dental sales tools and resources
- Annual Maximum Rollover
- Dental Blue Options
- SimplyBlue Plus Dental
- How Pediatric Dental Benefits Work
Dental at-a-glance charts
- Rochester region
- Syracuse region
- Albany, Mid-Hudson, Utica region
Vision sales tools and resources
- Simply Vision Plans
- Employer Simply Vision Plan Flyer
- Member Simply Vision Plan Flyer
- Davis Vision Discount Flyer
- Davis Vision Provider List
- Safety Eyeglass Program Flyer
Wellbeing tools and resources
ThriveWell
- ThriveWell Member Guide
- ThriveWell Quick Start Guide
- ThriveWell Member Program Flyer
- Rewards Points and Cash Flyer
- Rewards Flyer
- Foodsmart Flyer
* Rates shown are subject to approval by the New York State Department of Financial Services (NYS DFS)
THIS WEBSITE USES COOKIES
We use cookies and other technologies to optimize site functionality, analyze website traffic, and share information with social media, advertising, and analytics partners. See our Privacy Policy for how we use information.
GDPR Notification Content