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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, contact your Blue Cross of Idaho representative. Note: To print a PDF document, you need Adobe® Acrobat® Reader. Download it now for free.

Quick Links: Plans effective 1-1-14 and after
Plans effective before 1-1-14

Plans effective 1-1-14 and after

Form Name Form #
ENROLLMENT FORMS (eff 1-1-14 & after)

Small Group (2-50 employees)

 
Employee Waiver of Coverage 3-467
Employer Application & Group Questionnaire 2-50 Employees 3-549
Universal Idaho Small Employer Application 3-017

Medium Group (51-99 employees)

 
Application Cover Sheet for Group Dual Option (HSA) 3-128
Idaho Large Group Application Cover Sheet 3-186A
Idaho Large Group Application
3-186
Employer Application & Group Questionnaire 51 or more employees 3-550
Large Group Health Application without Health Statement 3-556

Large Group (100+ employees)

 
Application Cover Sheet for Group Dual Option (HSA) 3-128
Idaho Large Group Application Cover Sheet 3-186A
Idaho Large Group Application 3-186
Employer Application & Group Questionnaire 51 or more employees 3-550
Large Group Health Application without Health Statement 3-556
Large Group Health/Dental Application without Health Statement 3-393
ASC Group Health Enrollment Application 3-305
ASC Group Health/Dental Enrollment Application 3-307
SWS ASC Enrollment Form
3-307 SWS

Group Dental

Group Dual Option Dental Application 3-295

Ancillary

 
Group Voluntary Vision Enrollment Application 3-412
SALES LITERATURE

Group Dental

 
Group Dental Plans 3-765
Dental Maximum Carryover 3-829
Voluntary Dental 15-017

Ancillary Products

 
Employee Assistance Program 3-360
Nurse Advice Line 3-613
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 Prime 65 Plans F,K, M & N 4-164

Plans effective before 1-1-14

Form Name Form
ENROLLMENT FORMS  

Individual

 
Transfer Application 3-362

Small Group (2-50 employees)

 
Universal Idaho Small Employer Application 3-017
Employee Census Data 3-468
Idaho Small Employer Application Cover Sheet 3-366
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 Application without Health Statement 3-556
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
SWS ASC Enrollment Form
3-307 SWS
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
Certification for Mentally or Physically Handicapped Dependent 4-119
COBRA Group Coverage Continuation Application 4-149
Coordination of Benefits Form 5-172
Dental Claim Form 15-011
Direct Reimbursement Dental Claim Form 3-413
Member Name and Address Change 4-125
Notice to Applicant 6-111A
Nonsmoker Certification 3-319
HIPAA Authorization Form N/A
HSA Blue Benefit Change Request 3-137
Individual Product Policy Termination Request Form 3-628
SWS Retiree's Request for Benefits 4-150
Primary Care Physician Selection Form 3-912
BROCHURES
Behavioral Health Management 3-181
Blue Card Program 3-146
Blue Extras! 3-418
Finding a Dental Provider 3-872D
Finding a Dental Provider (spanish version) 3-872D-SP
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
Oral Health Brochure 3-179
Population Health Management N/A
Prescription Drug Formulary 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 Program Brochure 3-906
SWS Retiree Program FAQ Brochure 3-626
Ten Ways to Save on Healthcare Costs 3-028
Top Ten Things You Need To Know About Health Insurance 3-728
True Blue HMO for Statewide School 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
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