Blue Shield of California Forms
	Affidavit of Domestic Partnership Domestic partnership agreement, 1 Page (Rev. 1/05)
	BS PHI Disclosure Authorization Must be signed by the plan member to authorize Blue Shield to release personal & health information to a third party., 3 Pages
	BS Sole Proprietor, Partner or Corporate Officer Statement Small Group Requirements for proof of eligibility when owners not listed on the DE6, 1 Page (Rev. 1/04)
	BSLife Disability Addendum 1 Page (Rev. 1/04)
	BSLife Evidence of Insurability 2 Pages (Rev. 9/03)
	Direct Reimbursement Claim Form Prescription Drug Reimbursement Claim Form, 2 Pages (Rev. 04/07)
	Employee Application for Groups 2-50 (Fillable Form) Includes Waiver of Coverage. Must be completed by all enrolling employees. effective 1/08. Fillable forms are now available for applications and change forms, making it easier for your clients to apply or make changes to their Blue Shield coverage. These forms allow users to type information into the fields, print, sign, and fax to us. You can also send blank forms via email. Please note: Forms must be filled out and printed. Completed forms cannot be saved. Users cannot submit forms electronically. , 6 Pages (Rev. 07/08)
	Employee Health Statement Required for groups of 2-14 enrolling employees & non-GI groups only. Small groups who wish to be considered for an RAF other than standard may also submit Health Statements for consideration., 2 Pages (Rev. 12/07)
	Employee Medical Claim Form Employee Medical Claim Form (HMO,POS & PPO Plans), 1 Page (Rev. 8/02)
	Employer Questionnaire Health questionnaire for group 15-50, 2 Pages (Rev. 11/06)
	Master Group Application (Fillable Form) Group Application for groups 2-50. Fillable forms are now available for applications and change forms, making it easier for your clients to apply or make changes to their Blue Shield coverage. These forms allow users to type information into the fields, print, sign, and fax to us. You can also send blank forms via email. Please note: Forms must be filled out and printed. Completed forms cannot be saved. Users cannot submit forms electronically. , 6 Pages (Rev. 03/08)
	Master Group Application for Standalone Dental, Vision or Life Plans Group application for dental, vision, or life plans without Blue Shield medical coverage., 4 Pages (Rev. 1/07)
	Request for Continuity of Care Transfer of care form, 2 Pages (Rev. 1/07)
	Request for Contract Change Form (Fillable Form) This form should be used to expedite change requests for clients renewing group contracts. Fillable forms are now available for applications and change forms, making it easier for your clients to apply or make changes to their Blue Shield coverage. These forms allow users to type information into the fields, print, sign, and fax to us. You can also send blank forms via email. Please note: Forms must be filled out and printed. Completed forms cannot be saved. Users cannot submit forms electronically. , 2 Pages (Rev. 12/07)
	Subscriber Change Request (Fillable Form) Employee Change Request Form (English & Spanish). Fillable forms are now available for applications and change forms, making it easier for your clients to apply or make changes to their Blue Shield coverage. These forms allow users to type information into the fields, print, sign, and fax to us. You can also send blank forms via email. Please note: Forms must be filled out and printed. Completed forms cannot be saved. Users cannot submit forms electronically. , 2 Pages (Rev. 10/07)

Be sure you have the latest free version of Acrobat Reader from Adobe. This program will allow you to store and print the forms from your hard drive. If you do not have Adobe Acrobat Reader, click here or on the "Get Acrobat Reader" Image, to download the software.



For additional information, please contact Claremont at 800.696.4543 or info@claremontcompanies.com