Insurance Forms

Excellus BlueCross BlueShield
To enroll in an Excellus health plan, you must download the appropriate new group enrollment forms packet listed below. Once you have downloaded the forms packet, you will also need to download a rate sheet for the particular plan you have selected. The rate sheet link is also listed below.

• New group underwriting packet - HMO/EPO*
• New group underwriting packet - Healthy Blue*
• New Group Enrollment Forms packet - Simply Blue*
  
• Rate sheets

• Excellus Enrollment/ Change Form
• Excellus Healthy Blue Enrollment/Change Form
• Excellus Simply Blue Enrollment/Change Form
  
• BlueCross BlueShield Claim Forms

MVP Health Care

• New group MVP Health Care enrollment packet
• MVP Health Care enrollment/ change form
• MVP Health Care claim forms
• MVP health dollars/ Trivantage reimbursement form

Guardian DentalGuard Forms

• Guardian enrollment/ change form
• Guardian DentalGuard claim form

Dental Blue Forms

• New group underwriting packet
• Dental Blue Option 65 Rate Sheet
• Dental Blue Option 60 Rate Sheet
  
  

If you need additional information or have chosen a plan, please contact Nina Shelton at the RBA's Health Insurance Department at (585) 256-4644.

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