You can find any of the forms or applications by visiting www.arkansasbluecross.com
and logging in to BluesEnroll or by contacting your group service representive. If you need any forms other than
the ones indicated, or if you need other supplies that are not listed, please
contact your group service representative for assistance.
As the group administrator, we respectfully ask that you check each form
for completion, accuracy and timeliness. We are unable to process
incomplete forms, and this could delay your employee from receiving benefits.
Group Employee Application [pdf, 864 KB] Please use this form to enroll an employee in your group's health program.NOTE: BluesEnroll uses an online application to enroll an employee in a group's health program; an employee who declines coverage initially must complete the waiver section of the online application. All employees are required to complete an online application when enrolling.Incapacitated Dependent Form [pdf, 54 KB] Members who are in the process of requesting that a child be considered as an "incapacitated dependent" for continuing health coverage should use this form.Change Request Form [pdf, 465 KB] This form is used to make changes to a currently enrolled employee's address, name and telephone number or to cancel coverage for an employee and/or dependent(s).Dental Application and Change Form [pdf, 149 KB] This form is used to either enroll an employee in your group's dental program, or to make changes to a currently enrolled employee's coverage.Vision Application and Change Form [pdf, 149 KB] This form is used to either enroll an employee in your group's vision program, or to make changes to a currently enrolled employee's coverage.Health Claim Form [pdf, 81 KB] Use this form to submit medical charges for benefits that were not filed by the physician or health care professional. There are step-by-step instructions on how to file charges on the reverse side of the claim form.Dental Claim Form [pdf, 622 KB] This form is used to submit dental charges for benefits that were not filed by the dentist.Prescription Claim Form [pdf, 264 KB] This form is used to submit prescription charges for reimbursement in cases where
the member has made payments.
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Arkansas Blue Cross and Blue Shield is an Independent Licensee of the Blue Cross
and Blue Shield Association and is licensed to offer health plans in all 75 counties
of Arkansas. Copyright © 2001-2015 Arkansas Blue Cross and Blue Shield