Blue Access for Producers
 

Downloadable Forms for Individual Products

Here are some commonly used forms for conducting business with Blue Cross and Blue Shield of Oklahoma (BCBSOK). To access more downloadable forms, please log in to Blue Access for Producers.

The forms below are in portable document format (PDF). To view these files, you may need to install a PDF reader program. Most PDF readers are a free download. One option is Adobe® Reader®.

Current Individual Forms
Stock # / Date Enrollment Forms and Change Forms Oklahoma Form #
606465.1019 2020 Individual Paper Application Checklist N/A
73447.1019 Health Application/Change in Coverage – Use this health application for 2020 plans, effective January 1, 2020. N/A
600001.1019 Dental Application/Change in Coverage – Use this dental application for 2020 plans, effective January 1, 2020. N/A
601673.1019 2020 Individual Paper Application Overflow Page N/A
Stock # / Date Account Maintenance Forms Oklahoma Form #
72008.1018 Auto Bill Pay - Automatic Premium Payment Authorization Agreement N/A
600901.1018 Auto Bill Pay - Automatic Premium Payment Authorization Agreement - Spanish N/A
608020.0719 Disabled Dependent Authorization Form (for Individual Plans) – Members with an Individual health plan should use this form to request continuation of coverage on their existing policy for a dependent who is incapable of self-support because of mental or physical impairment. Mail or fax the completed form to BCBSOK (see address and fax number at the top of the form). N/A
Stock # / Date Legal / HIPAA Forms Oklahoma Form #
04.01.18 Standard Authorization Form and other HIPAA Privacy Forms N/A


Pre-ACA Individual Forms
Stock # / Date Enrollment Forms and Change Forms Oklahoma Form #
72120.1113 Health Check and Simply Blue Individual Application and Change in Membership  N/A
Stock # / Date Legal / HIPAA Forms Oklahoma Form #
04.01.18 Standard Authorization Form and other HIPAA Privacy Forms N/A