Employers

Group Administrator's Manual

Forms

Below are some of the most frequently used forms. If you need any forms other than the ones provided below, 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 to be submitted for completion, accuracy and timeliness. We apologize that we are unable to process incomplete forms, and this could delay your employee from receiving benefits.

  • Large Group Employee Application (PDF)
    Please use this form to enroll an employee in your group's health program. Employees who decline coverage when it is initially offered to them must complete the medical questionnaire when later applying for coverage.

    NOTE: BluesEnroll groups use 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.

  • Small Group Employee Application (PDF)
    Please use form to enroll an employee in your group's health program.

    NOTE: BluesEnroll groups use 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)
    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)
    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)
    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.

  • Application for Conversion Policy (PDF)
    If an employee is leaving your group coverage policy but wishes to continue to have coverage with Arkansas Blue Cross on an individual basis, he or she must complete this form. Conversion also is available to employees who have exhausted their COBRA eligibility. This form must reach our offices within 31 days of the last day the employee is covered through the group.

  • Health Claim Form (PDF)
    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)
    This form is used to submit dental charges for benefits that were not filed by the dentist.

  • Prescription Claim Form (PDF)
    This form is used to submit prescription charges for reimbursement in cases where payment has been made by the member.

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