Don't find
the form you need? Order it from
our Supply Specialist at (503) 225-4961.
| Forms |
Descriptions |
| ENROLLMENT FORMS |
| New
Enrollment and Change Form (PDF) |
Use this form to add a new employee
to your group plan or make changes such as
adding/deleting dependents, name change or changes
at open enrollment. |
| New
Enrollment and Change Form (PDF) - Spanish |
Use this form to add
a new employee to your group plan or make changes
such as adding/deleting dependents, name change
or changes at open enrollment. |
| Regence
Life & Health Enrollment Application (PDF) |
Use this
from to collect beneficiary information from your
employees if you have Regence Life & Health
Benefits. (This form is kept by the employer, not
by Regence BlueCross BlueShield of Oregon.) |
| Waiver
of Coverage
(PDF) |
Use this form for employees who decline
health-care coverage through Regence BlueCross BlueShield
of Oregon. |
| Waiver of Coverage (PDF) - Spanish |
Use this form for employees who decline health-care coverage through Regence BlueCross BlueShield of Oregon. |
| Employee
Enrollment Form (PDF) |
Insurance Pool Governing Board (IPGB)
form for Blue Solution only |
| Employer
Enrollment Data (PDF) |
Insurance Pool Governing
Board (IPGB) form for Blue Solution only |
| COBRA/CONTINUATION
FORMS |
| COBRA
Application and Notice (PDF) |
Use this form when an employee or
dependent chooses to continue group coverage after
a qualifying event. This form is for Oregon- and
Washington-based groups of 20 or more employees. |
| COBRA
Qualification Worksheet |
Use this worksheet to
see if your group qualifies for COBRA. |
| Oregon
Continuation Application and Notice (PDF) |
Use this form when an
employee or dependent chooses to continue group
coverage after a qualifying event. This form is
for Oregon-based groups with fewer than 20 employees. |
| Washington
Continuation Application and Notice (PDF) |
Use this form when an
employee or dependent chooses to continue group
coverage after a qualifying event. This form is
for Washington-based groups with fewer than 20 employees. |
| AUTHORIZATION FOR
USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION |
| Authorization
for Use and Disclosure of Protected Health Information (PDF) |
Authorization for Regence BlueCross
BlueShield of Oregon and/or a member's health-care
providers to disclose health information to a
designated party for a specific purpose. |
VERIFICATION FORMS |
| BlueChoicesSM
Accidental Death Claim Form (PDF) |
Applicable to Oregon
based groups, sizes 2-199, with BlueChoices products
only. Use this form when an enrolled employee, spouse
or dependent passes away due to an accidental death. |
| Affidavit of Qualifying Incapacitated Dependent Eligibility (PDF) |
Use this form to certify that your eligible dependent child is incapacitated due to medical disability, developmental disability or mental disorder. |
| Certificate
of Paternity (PDF) |
Use this form to prove that a individual
is the natural father of a dependent. |
| Certification of Dependency |
Use this form to prove that an individual
is a legal dependent of the member (usually required
for dependents other than natural children). |
| Affidavit
of Domestic Partner (PDF) |
Employees and their domestic
partners applying for coverage should complete this
form. Domestic partner coverage is available to
select groups with more than 50 subscribers. |
| Certification
of Marriage (PDF) |
Use this form to provide
information regarding an employee's marriage status
in cases where the eligibility of the spouse is
in question (e.g., different last names). |
| Certification
of Placement - Oregon (PDF) |
Use this
form when a child has been adopted or physically
placed with an employee for the purposes of adoption.
The employee must assume financial responsibility
for the dependent's medical expenses. |
| Certification
of Placement - Washington (PDF) |
Use this form when a child has been
adopted or physically placed with an employee for
the purposes of adoption. The employee must assume
financial responsibility for the child's medical
expenses. |
| Statement
of Termination of Domestic Partnership |
Use this form to indicate the termination
of a domestic partnership due to change in circumstance
or death. |
| Employer
Affidavit (PDF) |
Insurance Pool Governing Board (IPGB)
form for Blue Solution only |
PRESCRIPTION MEDICATION
MAIL-ORDER FORMS
Now located on the RegenceRx
Web site. |
| Prescription
Mail Order (PPS) Form (PDF) |
Members can use this form to order new prescriptions from PPS mail-order service.
For prescription refills and other information, visit the PPS Web site. |
PRESCRIPTION AND
DURABLE MEDICAL EQUIPMENT REIMBURSEMENT FORM |
| Filing a Claim (PDF) |
This flyer explains what to do when you receive a bill from your provider. |
| Medication Claim Form (PDF) |
Use this form for reimbursement when the pharmacy did not have your member card information to process your claim online. Applicable to plans that allow the pharmacy to submit claims online for you and collect a copay at time of purchase. |
| Durable Medical Equipment & Medical Supply Claim Form |
Use this form to submit
a durable medical equipment claim for reimbursement on PPO and Traditional
plans. |
| Prescription Medication Claim Form (PDF) |
Use this form to submit claims
for durable medical equipment or prescription plans that
require members to pay out of pocket and submit for
reimbursement. |
| FORMS REQUESTING ADDITIONAL
INFORMATION |
| Coordination
of Benefits Report (PDF) |
Use this form when Regence
needs to verify a member's other insurance coverage. |
| Incident
Report (PDF) |
Use this form to verify
accident information and third-party liability. |
| FORMS FOR GROUP ADMINISTRATOR
USE ONLY |
| Application
for Group Coverage (PDF) |
Use this form to provide initial
group setup information. If your group size is
2-50 in Oregon, or 1-50 in Washington, please
use our Online
Enrollment System. |
| Annual
Census Form - Oregon (PDF) |
Use this form annually
to verify group information. Use this form for Oregon-based
groups with 50 or fewer employees only. |
| Annual
Census Form - Washington (PDF) |
Use this form annually
to verify group information. Use this form for Washington-based
groups with 50 or fewer employees only. |
| Application
for Group Coverage - AFC (PDF) |
Use this form to provide
initial group setup information. For groups of 51
or more eligible employees only. |
| Eligibility
Adjustments |
Use this form to calculate premium
due when new enrollment, status changes or member
cancellations have been made. |
| TruVision™ |
Our new discount vision care program |
| Group
Census |
Insurance Pool Governing
Board (IPGB) form for Blue Solution only |
Don't find the form you need? Order it from our Supply Specialist at (503) 225-4961.
