2008 Enrollment Forms Packets

• Excellus BCBS Change / New Enrollment Forms Packet
• Excellus BCBS Healthy Blue Enrollment Forms Packet
• Preferred Care Change / New Enrollment Forms Packet
• Preferred Care EPO Enrollment Forms Packet
  

Excellus BlueCross BlueShield forms

Enrollment and change forms
New members enrolling must complete forms marked with an '*'

• (*)BlueCross Enrollment/Change Form - Application for enrollment and contract status change form. Payment must accompany application. Contact the Insurance Department for premium due.
• (*)BCBS Healthy Blue Enrollment/Change Form - Application for Healthy Blue enrollment & contract status change. Payment must accompany application. Contact the Insurance Department for premium due. This application is only for Healthy Blue. All other plans use application above.
  
• (*)BCBS Underwriting Guidelines - Eligibility requirements for new employer groups applying for BlueCross.
• (*)Member Group Information Worksheet - Necessary for all new employer groups applying for any BlueCross products.
• (*)Attestation Form - Necessary for anyone who does not appear on the NYS-45-ATT-MN
• (*)Employee Waiver for Group Health Insurance - Needed for employees who opt out of group health or dental plan.
• (*)Employer Variance Request - Needed to establish employers hire policy for offering benefits to employees
• BCBS Foster/Adoption Dependent Enrollment - Needed to add dependent
• BCBS Rochester Region PHI Disclosure Form - Authorization to disclose information form. Only needed if Rochester Business Alliance needs to check on medical claims for subscriber.
• BCBS Medicare Carve-Out Election Form - Needed for anyone becoming Medicare eligible and retaining under 65 benefits.

Preferred Care forms

Enrollment and change form

New members enrolling must complete forms marked with an '*'

• (*)Preferred Care Enrollment/Change Form - Application for enrollment & contract status change form. Contact the Insurance Department for premium due.
• (*)Preferred Care Broker's Letter of Record Form - Letter should be signed and copied onto a piece of your company letterhead and returned with support documentation showing employment or business ownership. (Ex: DBA certificate, Schedule C or Certificate of Incorporation).
• Preferred Care PHI Disclosure Form - Authorization to disclose information form. Only needed if Rochester Business Alliance needs to check on medical claims for subscriber.

Guardian DentalGuard forms

Enrollment and change form

• Guardian DentalGuard Enrollment/Change Form - Application for enrollment & contract status change form. Payment must accompany application. Contact the Insurance Department for premium due.

Claim Forms

Claim forms should be completed and mailed directly to the insurance carrier, not the RBA.

• Blue Cross Claim Form
• Preferred Care Claim Form
• Preferred Care Health Dollars / Trivantage Reimbursement Form
  
• Guardian DentalGuard Claim Form

To obtain forms not listed here, please contact the Rochester Business Alliance Insurance Department at (585) 256-4644.