RESOURCE CENTER

Client Service Forms
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10.30.2012
Employee Enrollment-Change form (for EXISTING group)
Enrollment form to be completed by employee, for a EXISTING group with new hire/life event or existing member changing dependent coverage. This form cannot be used for new business or PPO 1-2-3 plans. *released 8/2012
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10.30.2012
Employee Enrollment form (for PPO 1-2-3 plans)
Enrollment form to be completed by employee, for a PPO 1-2-3 plan submission. This form cannot be used for existing group or new business. *released 8/2012
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10.30.2012
Application for 2-50 Group Benefits
Enrollment form to be completed by employer with 2-50 eligible employees, for new or renewal. Contains verbiage for CAAC. *released 8/2012
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09.24.2012
MLR Questionnaire
Required for new business beginning with 11/1/12 effective dates. This form helps CBC obtain required information important to determining future MLR rebate status.
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09.21.2012
Blue Cross Dental-Vision Enrollment Form (released 8/2012)
Enrollment form to be completed by employer, when adding members to a Blue Cross Dental or Blue Cross Vision plan.
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05.21.2012
Value Based Benefits - Setup Form
CBC launched Value Based Benefits on 7/2012 for large groups with 100+ employees. Employers can choose from 6 health incentive programs. The form is required to setup a group with the program.
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04.27.2011
HIPPA Disclosure form
CBC branded form to be completed by the member in order for PHI to be disclosed to a 3rd party
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