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Forms and Brochures

The following is a list of forms available in a PDF pdf icon format. To print a single form, click on the form name and it will open a printable PDF file. To order a larger supply, click here. Note: To print a PDF document, you need Adobe® Acrobat® Reader. Download it now for free.

Quick Links: Enrollment Forms
Member Forms
Brochures
Sales Literature
Form Name Form
ENROLLMENT FORMS

Small Group (2-50 employees)

 
Group Questionnaire for New Groups 2-50 Employees 3-469
Universal Idaho Small Employer Application 3-017
Employee Census Data 3-468
Idaho Small Employer Application Cover Sheet 3-366
Application for Small Employer Coverage 3-470
Employee's Waiver of Health Care Coverage 3-467
Letter of Record  3-302
Managed Care Group Questionnaire for New Groups 2-50 Employees 3-242
Application Cover Sheet for Group Dual Option (HSA) 3-128

Medium Group (51-99 employees)

 
Group Questionnaire for New Groups - 51 or more employees 3-471
Employee Census Data 3-468
Application for Medium/Large Employer Coverage 3-326
Large Group Health Application with Health Statement 3-300
Large Group Health/Dental Enrollment Application with Health Statement 3-301
Employee's Waiver of Health Care Coverage 3-467
Letter of Record  3-302
Application Cover Sheet for Group Dual Option (HSA) 3-128

Large Group (100+ employees)

 
Group Questionnaire for New Groups - 51 or more employees 3-471
Employee Census Data 3-468
Application for Medium/Large Employer Coverage 3-326
Employee's Waiver of Health Care Coverage 3-467
Letter of Record  3-302
Application Cover Sheet for Group Dual Option (HSA) 3-128
Large Group Health Application with Health Statement 3-300
Large Group Health Application without Health Statement 3-556
Large Group Health/Dental Enrollment Application with Health Statement 3-301
Large Group Health/Dental Application without Health Statement 3-393
ASC Application/ Questionnaire for New Groups 3-437
ASC Group Health Enrollment Application 3-305
ASC Group Health/Dental Enrollment Application  3-307
Managed Care Group Questionnaire for New Groups 51 or More Employees  3-243
Managed Care ASC Application/Questionnaire for New Groups 3-244

Other

 
COBRA Rate Agreement (ASC) 3-357

Ancillary

 
Group Stand Alone Dental Enrollment Application 3-395
Group Voluntary Dental Application  3-309
Group Voluntary Vision Enrollment Application  3-412
Premium Only Plan (POP) Enrollment Application 3-225a
MEMBER FORMS  
Accidental Injury Questionnaire  5-118
Authorization Agreement for Prearranged Payments 3-449
Member Claim Form 5-175
COBRA Group Coverage Continuation Application 4-149
Coordination of Benefits Form 5-172
Dental Claim Form 15-011
Nonsmoker Certification  3-319
HIPAA Authorization Form  N/A
HSA Blue Benefit Change Request 3-137
Individual Product Policy Termination Request Form 3-628
Primary Care Physician Selection Form 3-912
SWS Retiree Application  4-150
BROCHURES
Blue Card Program 3-146
Blue Extras!  3-418
Generic Equivalent letter  3-211
Generic Medications: What You Should Know  3-210
Member Registration Instructions 4-126
Multi-Tier Pharmacy Benefit FAQ's 3-219
Online Tools 3-810
Population Health Management Prescription Drug Formulary  N/A 3-218
Prescription Drug Plans Creditable Under Medicare Part D  3-684
Prior Authorization Brochure 3-241
Provider Network - Preferred Blue Brochure 14-005
SWS Retiree Brochure  3-906
Ten Ways to Save on Healthcare Costs 3-028
Top Ten Things You Need To Know About Health Insurance  3-728
True Blue for Statewide Schools Retirees  16-106
VSP List of Participating Doctors 3-349
SALES LITERATURE

Individual - Medical

 
BlueCare® PPO 3-323
Essential BlueSM Basic 3-136
Essential BlueSM Plus 3-144
HSA BlueSM PPO 3-296
Simply Blue Brochure 3-622
Individual Program Premiums - RL1 3-431
Prime 65sm Medicare Supplement Brochure 3-023
Short Term BlueSM Brochure & Application 3-528 & 3-580
Short Term Blue - Rate Card  3-528a
State Mandated High Risk Pool (HRP) products  3-313

Small Group (2-50 employees)

 
  Healthy Measures  3-121
Small Group Overview 3-734

Medium/Large Group (51+ employees)

 
Healthy Measures  3-121
Large Group Overview 3-733

Group Dental

 
Group Dental Plans 3-795
Dental Maximum Carryover 3-829
Voluntary Dental 15-017

Group Ancillary Products

 
Employee Assistance Program 3-360
Premium Only Plan 3-225
VSP – Plan C-I  3-425
VSP – Plan C-II  3-426
VSP – Plan C-III  3-427
VSP - Voluntary (12/12) $10/25 Copay  3-353
VSP - Voluntary (12/12) $20/25 Copay  3-354
VSP - Voluntary (12/24) $10/25 Copay  3-355
VSP - Voluntary (12/24) $20/25 Copay  3-359
VSP - Exam Only/$10  3-370
VSP - Exam Only/$20  3-371
VSP - Exam Only/$25  3-374
VSP - Exam with Allowance $100/12  3-361
VSP - Exam with Allowance $125/12  3-363
VSP - Exam with Allowance $150/12  3-364
VSP - Exam with Allowance $100/24  3-365
VSP - Exam with Allowance $125/24  3-367
VSP - Exam with Allowance $150/24  3-368
VSP Flyer for Classic Blue Plan F 4-164