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Blue Shield of California
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Blue Shield of California Checklist
New Group submission checklist., 1 Page (Rev. 8-2011)
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BS Application - Employer
New groups enrolling on or after January 1, 2012
Rev2, 8 Pages (Rev. R2 8-2011)
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BS Employee Application
Employees should complete this form to enroll in a group medical plan, group vision plan or group term life policy.
Rev, 7 Pages (Rev. R 8-2011)
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Domestic Partnership Affidavit
Employees must complete and submit this form along with their Enrollment Applications or within 31 days of establishing or terminating a domestic partnership.
, 1 Page (Rev. 1/2005)
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Domestic Partnership Statement
Domestic partnership agreement, 1 Page (Rev. 08/06)
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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. 3/10)
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Employer Questionnaire
For 15 to 50 enrolling employees, 2 Pages (Rev. 8/2011)
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Group Change Transmittal/Termination
Used to fax Group changes, termination or additions for Medical and Dental., 1 Page (Rev. 06/10)
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HIPPA Disclosure Authorization
Must be signed by the plan member to authorize Blue Shield to release personal & health information to a third party., 2 Pages (Rev. 8/07)
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Language Assistance Program
Used for employees to obtain free help in translating vital medical documents, 2 Pages (Rev. 01/09)
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Medical Claim Form
Employees should use this form ONLY when the Provider of Service does not submit their claim directly to Blue Shield. This is for Blue Shield Life plans.
, 1 Page (Rev. 03/07)
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Medical Claim Form
Employees should use this form ONLY when the Provider of Service does not submit their claim directly to Blue Shield. This is for Blue Shield of California plans.
, 1 Page (Rev. 01-07)
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Prescription Direct Reimbursement Claim Form
Prescription Drug Reimbursement Claim Form, 2 Pages (Rev. 6/09)
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Prior Carrier Accumulation
Used to submit to Blue Shield for Credit of Prior Deductible., 1 Page (Rev. 08/09)
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Refusal of Personal Coverage
Complete if you, your spouse, domestic partner or dependent(s) are refusing your employers Blue Shield health or dental coverage., 1 Page (Rev. 5/10)
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Sole Proprietor, Partner or Corporate Officer Statement
Small Group Requirements for proof of eligibility when owners not listed on the DE6, 1 Page (Rev. 6/10)
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Subscriber Change Request
Employees can change personal information, change plans during open enrollment, enroll new dependents or cancel dependents (include Refusal or Cancellation of Personal Coverage form).
, 5 Pages (Rev. 8/2011)
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Verification and Statement of Understanding
New groups enrolling on or after January 1, 2012
, 1 Page (Rev. 9/2011)
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Vision Claim Form
Used for submitting Vision Claims to Blue Shield, 1 Page (Rev. 3-09)
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Base PPO30
The following benefit summary is effective January 1 through June 30, 2012 unless otherwise noted., 4 Pages (Rev. R1/2012)
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Base PPO40
The following benefit summary is effective January 1 through June 30, 2012 unless otherwise noted., 4 Pages (Rev. R1/2012)
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Base PPO50
The following benefit summary is effective January 1 through June 30, 2012 unless otherwise noted., 4 Pages (Rev. R1/2012)
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Simple Savings 2500-5000
The following benefit summary is effective January 1 through June 30, 2012 unless otherwise noted., 4 Pages (Rev. R1/2012)
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Simple Savings 3400-6800
The following benefit summary is effective January 1 through June 30, 2012 unless otherwise noted., 4 Pages (Rev. R1/2012)
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Simple Savings 3500-7000
The following benefit summary is effective January 1 through June 30, 2012 unless otherwise noted., 4 Pages (Rev. R1/2012)
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Simple Savings 4500-9000
The following benefit summary is effective January 1 through June 30, 2012 unless otherwise noted., 4 Pages (Rev. R1/2012)
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Simple Savings 5500-11000
The following benefit summary is effective January 1 through June 30, 2012 unless otherwise noted., 4 Pages (Rev. R1/2012)
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Enhanced PPO15
The following benefit summary is effective January 1 through June 30, 2012 unless otherwise noted., 4 Pages (Rev. R1/2012)
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Enhanced PPO25
The following benefit summary is effective January 1 through June 30, 2012 unless otherwise noted., 4 Pages (Rev. R1/2012)
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Enhanced PPO30
The following benefit summary is effective January 1 through June 30, 2012 unless otherwise noted., 4 Pages (Rev. R1/2012)
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Enhanced PPO35
The following benefit summary is effective January 1 through June 30, 2012 unless otherwise noted., 4 Pages (Rev. R 1/2012)
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Enhanced PPO40
The following benefit summary is effective January 1 through June 30, 2012 unless otherwise noted., 4 Pages (Rev. R1/2012)
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Enhanced PPO45
The following benefit summary is effective January 1 through June 30, 2012 unless otherwise noted., 4 Pages (Rev. R1/2012)
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Premier PPO 5
The following benefit summary is effective January 1 through June 30, 2012 unless otherwise noted., 4 Pages (Rev. R1/2012)
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Premier PPO15
The following benefit summary is effective January 1 through June 30, 2012 unless otherwise noted., 4 Pages (Rev. R1/2012)
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Premier PPO20
The following benefit summary is effective January 1 through June 30, 2012 unless otherwise noted., 4 Pages (Rev. R1/2012)
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Premier PPO25
The following benefit summary is effective January 1 through June 30, 2012 unless otherwise noted., 4 Pages (Rev. R1/2012)
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Premier PPO35
The following benefit summary is effective January 1 through June 30, 2012 unless otherwise noted., 4 Pages (Rev. R1/2012)
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Premier PPO45
The following benefit summary is effective January 1 through June 30, 2012 unless otherwise noted., 4 Pages (Rev. R1/2012)
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Shield Spectrum PPO 1000V
The following benefit summary is effective January 1 through June 30, 2012 unless otherwise noted., 4 Pages (Rev. R1/2012)
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Shield Spectrum PPO 1500V
The following benefit summary is effective January 1 through June 30, 2012 unless otherwise noted., 4 Pages (Rev. R1/2012)
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Shield Spectrum PPO 2500V
The following benefit summary is effective January 1 through June 30, 2012 unless otherwise noted., 4 Pages (Rev. R1/2012)
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Shield Spectrum PPO 750V
The following benefit summary is effective January 1 through June 30, 2012 unless otherwise noted., 4 Pages (Rev. R1/2012)
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Access+ HMO Enhanced15
The following benefit summary is effective January 1 through June 30, 2012 unless otherwise noted., 4 Pages (Rev. R 1/2012)
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Access+ HMO Enhanced25
The following benefit summary is effective January 1 through June 30, 2012 unless otherwise noted., 4 Pages (Rev. R 1/2012)
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Access+ HMO Enhanced35
The following benefit summary is effective January 1 through June 30, 2012 unless otherwise noted., 4 Pages (Rev. R 1/2012)
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Access+ HMO Enhanced40
The following benefit summary is effective January 1 through June 30, 2012 unless otherwise noted., 4 Pages (Rev. R1/2012)
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Access+ HMO Enhanced45
The following benefit summary is effective January 1 through June 30, 2012 unless otherwise noted., 4 Pages (Rev. R 1/2012)
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Access+ HMO Premier15
The following benefit summary is effective January 1 through June 30, 2012 unless otherwise noted., 4 Pages (Rev. R 1/2012)
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Access+ HMO Premier25
The following benefit summary is effective January 1 through June 30, 2012 unless otherwise noted., 4 Pages (Rev. R/1-2012)
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Access+ HMO Premier35
The following benefit summary is effective January 1 through June 30, 2012 unless otherwise noted., 4 Pages (Rev. R 1/2012)
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Access+ HMO Premier45
The following benefit summary is effective January 1 through June 30, 2012 unless otherwise noted., 4 Pages (Rev. R 1/2012)
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Local Access+ HMO Enhanced15
The following benefit summary is effective January 1 through June 30, 2012 unless otherwise noted., 4 Pages (Rev. R1/2012)
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Local Access+ HMO Enhanced25
The following benefit summary is effective January 1 through June 30, 2012 unless otherwise noted., 4 Pages (Rev. R1/2012)
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Local Access+ HMO Enhanced35
The following benefit summary is effective January 1 through June 30, 2012 unless otherwise noted., 4 Pages (Rev. R1/2012)
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Local Access+ HMO Enhanced45
The following benefit summary is effective January 1 through June 30, 2012 unless otherwise noted., 4 Pages (Rev. R1/2012)
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Local Access+ HMO Premier15
The following benefit summary is effective January 1 through June 30, 2012 unless otherwise noted., 4 Pages (Rev. R1/2012)
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Local Access+ HMO Premier25
The following benefit summary is effective January 1 through June 30, 2012 unless otherwise noted., 4 Pages (Rev. R1/2012)
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Local Access+ HMO Premier35
The following benefit summary is effective January 1 through June 30, 2012 unless otherwise noted., 4 Pages (Rev. R1/2012)
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Local Access+ HMO Premier45
The following benefit summary is effective January 1 through June 30, 2012 unless otherwise noted., 4 Pages (Rev. R1/2012)
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For additional information, please contact Claremont at 800.696.4543
or info@claremontcompanies.com
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