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Dental Employer Application
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5/18/2012
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Download
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Employer Group Medical Questionnaire 4-50
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5/17/2012
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Download
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Enrollment Summary **Renewals Only**
Description:
2011 revisions as follows: 1) COBRA Compliance section removed. 2) Common Ownership/Controlled Grp Compliance information added
(pdf
, 296k)
Version: 7823SR_0810
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1/25/2011
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Download
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Health Master Application--20741
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6/9/2009
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Download
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LgGrp RAQ_50+ Underwriting Questionnaire_rev 10-10
Description:
51+ Elig, Lg Grp Underwriting Questionnaire
(pdf
, 263k)
Version: 9582-1293_rev10
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1/3/2011
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Download
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Life Master Application--50648
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5/7/2009
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Download
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Small Group Checklist
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7/20/2012
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Download
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Employee Change Form
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5/21/2012
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Download
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Employee Change Form - Spanish
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5/21/2012
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Download
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Employee Enrollment Form
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5/21/2012
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Download
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Employee Enrollment Form - Spanish
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5/21/2012
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Download
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Evidence of Insurability Enrollment form--50474
Description:
Life, Voluntary Life and Disability
(pdf
, 182k)
Version: rev 0109
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5/7/2009
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Download
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FCL Employee Enrollment Form - Life & Dental
Description:
Use only if Evidence of Insurability is not required
(pdf
, 444k)
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5/23/2012
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Download
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Notice of Special Enrollment Rights--15741
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10/28/2009
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Download
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Administration Guide_BluesEnroll HR_Aug 2010
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9/27/2010
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Download
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Blue Dental Choice & CR Rated Matrix
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5/23/2012
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Download
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BlueBiz Administrator Access Form
Description:
Group Administrator Form for Access to online administration tools included in BlueBiz web portal.
(pdf
, 179k)
Version: 66646_10-10
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11/22/2010
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Download
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BlueDental Care Admin Guide (DMO product)
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5/21/2012
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Download
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BlueDental Choice and Freedom Admin Guide (PPO)
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5/21/2012
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Download
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BlueDental Contacts_Choice PPO & Care DMO
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5/21/2012
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Download
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BluesEnroll Quick Tips
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5/21/2012
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Download
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Change Form BlueDental Choice- Freedom- 50415
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9/10/2009
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Download
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Change Form--BlueDental Care DMO--50402
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9/10/2009
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Download
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Medical Administrative Guide
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5/21/2012
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Download
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Authorization for Release of PHI
Description:
authorization for individual/company to have access to confidential health information
(pdf
, 88k)
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7/6/2005
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Download
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Case Management Referral Form
Description:
Program provides additional assistance to members with complex or serious medical conditions.
(pdf
, 423k)
Version: 12-09
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1/25/2010
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Download
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Jan 1 2011_Rx Forms Pkg_UM Authorizations
Description:
Package includes both Open and Closed Formulary Guides, Responsible Steps and Precertification Medication Tables with links to appropriate request forms
(pdf
, 2366k)
Version: 010611
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1/6/2011
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Download
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Outpatient Behavioral Health Authorization Form
Description:
This program is applicable to all groups with 51 or more members. Authorization is required for services rendered on January 16, 2010 or later. Tip sheet included in the attachment.
(pdf
, 988k)
Version: 01-2010
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1/25/2010
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Download
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PPO Claim form
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1/28/2004
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Download
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Prescription Drug Claim form
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1/19/2007
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Download
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Prime RX Mail Order form
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5/21/2012
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Download
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Amendment Application_Small Grp_20752_0609
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9/29/2010
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Download
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Commission Direct Deposit Form
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5/23/2012
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Download
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Preventative Care Guidelines_69073-1110
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1/25/2011
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Download
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Quote form for LTD-VLTD
Description:
Form required for quoting LTD/VLTD
(pdf
, 247k)
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10/30/2009
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Download
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